• 


V 


OBSTETEICS. 

Cazeaux  and  Taenier 


EIGHTH  AMERICAN  EDITION. 

WITH  APPENDIX  BY  PAUL  F.  MUNDfi,  M.D., 
AND  NEW  ILLUSTRATIONS. 

IN   TWO   VOLUMES. 


Plate    I. 


For  Explanation  see  Page  92. 


CAZEAUX   and    TARNIER. 


THE 


THEORY   AND    PRACTICE 


OF 


OBSTETRICS ; 


INCLUDING  DISEASES  OF  PREGNANCY  AND  PARTURITION, 
OBSTETRICAL  OPERATIONS,  ETC. 

By   P.    CAZEAUX, 

MEMBER   OF    THE    IMPERIAL    ACADEMY   OP    MEDICINE,    ADJUNCT    PROFESSOR   IN    THE    FACULTY   OF   MEDICINE,    PARIS,   ,KTC. 

REMODELLED  AND  REARRANGED,  WITH  ADDITIONS  AND  REVISIONS, 
By   S.   TARNIER, 

PROFESSOR   OF   OBSTETRICS    AND   DISEASES   OF   WOMEN   AND   CHILDREN    IN    THE   FACULTY   OF    MEDICINE,    OF    PARIS. 

THE    EIGHTH    AMERICAN    EDITION. 

Edited  and  Revised  by  ROBERT  J.  HESS,  M.D., 

PHYSICIAN    TO    THE    NORTHERN    DISPENSARY,    PHILADELPHIA. 

WITH    AN    APPENDIX, 

By    PAUL    F.    MUNDE,   M.  D., 

PROFESSOR   OF    GYNECOLOGY    AT    THE   NEW    YORK    POLYCLINIC   AND   AT    DARTMOUTH    COLLEGE;     VICE-PRESIDENT 

AMERICAN    GYNECOLOGICAL   SOCIETY,    ETC. 

WITH  CHROMOLITHOGRAPHS,  LITHOGRAPHS  AND  OTHER  FULL-PAGE  PLATES, 
AND  ONE  HUNDRED  AND  SEVENTY-FIVE  WOOD  ENGRAVINGS. 

VOLUME     I. 
PHILADELPHIA: 

P.    BLAKISTON,    SON    &    CO., 
1012    Walnut    Street. 

1887. 


w  G 


COPYRIGHT,   188G,   BY  P.   BLAKISTOX,   SON  &  Co. 


PREFACE  TO  THE  NEW  EDITION. 


In  offering  this  new  American  edition  of  the  classical  work  of  Cazeaux 
and  Tarnier  to  the  profession,  an  apology  is  scarcely  necessary.  The  previous 
editions  have  long  since  been  exhausted,  and  although  references  to  it  in  the 
pages  of  medical  literature  are  frequent,  most  of  the  works  upon  the  science 
and  art  of  obstetrics  which  since  then  have  been  favorably  received  by  the 
profession  have  gleaned  much  of  their  worth  from  its  valuable  teachings. 
The  student  of  less  elaborate  text-books  is  likely,  at  the  present  day,  to  over- 
look the  foundation  principles  upon  which  the  science  has  been  built,  of 
which  these  distinguished  authors  have  been  for  many  years  the  honored 
teachers. 

The  present,  with  slight  omissions,  embraces  all  that  was  originally  con- 
tained in  previous  American  editions. 

A  later  French  edition,  and  also  an  Italian,  issued  during  the  past  year, 
the  latter  with  notes  by  Chiara,  Morisani,  Tibone,  and  Porro,  have  been 
consulted  in  its  preparation,  and  we  trust  it  will  be  found  to  contain  the 
newest  observations  in  obstetrical  science  made  possible  by  the  advance  in 
every  department  of  knowledge  relating  thereto. 

We  have  been  careful  to  avoid  any  change  in  the  principles  of  practice  as 
taught  by  Cazeaux  and  Tarnier,  deeming  the  acceptance  of  them  by  the 
profession  in  the  past,  and  the  frequent  reference  to  them  by  authors  of  the 
present,  as  the  most  certain  test  of  their  value,  while  the  latest  contributions 
of  the  present  time  in  each  department  of  the  science  have  been  carefully 
and  freely  introduced,  due  credit  being  given,  so  that  this  edition  will  reflect 
the  best  practice  of  the  best  authorities,  and  be  a  complete  guide  to  the 
student  and  a  source  from  which  the  profession  may  continue  to  draw  rich 
suggestions  in  this,  the  highest  branch  of  the  science  and  art  of  medicine. 

ROBERT  J.  HESS,  M.D. 

I'll!  LADELPHIA. 


3  I  3oy 


PREFACE  TO  THE  FRENCH  EDITION. 


THE  sixth  edition  of  this  work  was  almost  exhausted,  when  its 
author,  in  the  full  strength  of  years  and  talent,  was  suddenly  struck 
down  by  the  disease  which  very  soon  proved  fatal.  In  departing, 
Cazeaux  left  a  name  beloved  of  physicians  and  students,  and  respected 
by  all.  The  success  of  his  work  on  obstetrics  had  greatly  contributed 
to  extend  his  reputation  and  scientific  authority.  Inasmuch,  therefore, 
as  the  stoppage  of  its  publication  would  deprive  the  medica1  public  of 
a  work  which,  for  a  long  time,  has  justly  been  ranked  first  amongst 
classical  books,  both  Cazeaux's  family  and  his  editor  concurred  in  the 
opinion  that  a  new  edition  ought  to  be  published. 

A  classical  book  soon  grows  old  in  these  days,  and  it  was  found  im- 
possible to  bring  out  a  new  edition  without  subjecting  it  to  the  altera- 
tions demanded  by  the  progress  of  science.  I  was  charged  with  its  pre- 
paration, and  accepted  the  honor  of  the  task  with  a  full  appreciation  of 
its  difficulties.  I  had  never  been  Cazeaux's  pupil,  but  his  book  was  the 
first  from  which  I  had  studied  obstetrics,  and  I  had  been  accustomed  10 
see  it  in  the  hands  of  all  my  fellow-students,  and,  at  a  later  period,  of 
my  pupils  also.  Independently,  therefore,  of  my  personal  observa- 
tion, I  was  in  a  position  to  become  acquainted  with  its  character  through 
others.  Thus,  together  with  merited  praise,  I  sometimes  also  listened 
to  criticisms  of  its  details,  and  profited  by  all  I  heard. 

I  was  left  at  liberty  to  remodel  the  work  according  to  my  judgment, 
to  make  the  alterations  which  seemed  to  be  required,  to  suppress  some 
passages  and  to  introduce  new  ones.  Out  of  respect  to  Cazeaux's 
memory,  it  was  decided  that  the  printing  should  be  done  in  two  kinds 
of  type ;  the  larger  for  the  old  text,  and  the  smaller  for  what  I  had 
myself  written. 

The  reader  will  readily  distinguish  what  belongs  to  Cazeaux  and 
what  to  myself,  but  the  work  has  been  resolved  into  a  homogeneous 
body  without   contradictory  annotations.     This   last  result  could   not 


Viii  PREFACE. 

possibly  have  been  attained  without  retouching  the  old  text,  by  which 
a  new  direction  and  meaning  has  been  sometimes  given  to  the  original 
ideas.  Should  it  be  desired  to  know  certainly  what  Cazeaux's  opinions 
were,  it  will,  therefore,  be  necessary  to  consult  an  old  edition. 

Especially  have  I  made  it  a  duty  not  to  change  the  spirit  in  which 
the  work  had  been  conceived ;  therefore  I  can  say  with  Cazeaux,  that, 
'•  A iur  a  work  has  passed  through  several  editions,  a  preface  is  hardly 
needed,  for  its  object  is  then  sufficiently  well  known.  The  present  is 
more  particularly  intended  for  the  use  of  students  of  medicine  and  mid- 
wife-students, although  general  practitioners  may  also,  perhaps,  gain 
something  by  its  perusal,  for  I  have  endeavored  to  make  it  a  condensed 
summary  of  the  leading  principles  established  by  the  masters  of  our 
art,  and  for  that  purpose  have  drawn  from  all  the  works  published 
down  to  the  present  day.  My  position  in  the  lying-in  hospitals  has 
enabled  me  to  test  the  value  of  the  doctrines  put  forth  by  former 
authors ;  and  I  have  adopted  as  true  all  which  my  daily  experience  has 
confirmed,  and  have  rejected  unhesitatingly,  from  whatever  source  they 
came,  all  such  as  were  disproved  by  the  numerous  cases  brought  under 
my  observation,  confining  myself  to  quoting,  Avithout  comment,  those 
whose  value  I  have  been  unable  to  determine. 

"Although  this  work  resembles,  in  its  general  arrangement,  most  of 
those  published  on  the  same  subject  in  France,  it  differs  from  them 
essentially  in  the  main ;  for  I  have  adopted  almost  wholly  the  views  of 
Professors  Nsegele,  P.  Dubois,  and  Stoltz,  which  are  uot  found  clearly 
expressed  in  any  of  our  classical  books.  I  have  also  extracted  freely 
from  the  learned  treatise  of  Professor  Velpeau,  whow  vast  erudition 
has  greatly  facilitated  my  bibliographical  researches;  trorn  the  course 
of  my  former  teacher,  Professor  Moreau;  from  the  excellent  articles  of 
Desormeaux,  of  Duges,  and  of  Guillemot;  from  the  classical  works 
of  England  and  America,  such  as  those  of  Burns,  Campbell,  Merriman, 
Ramsbotham,  Dewees,  Meigs,  and  Rigby  ;  and  from  the  treatises  of  Peu, 
Delamotte,  Levret,  Smellie,  Baudelocque,  Gardien,  and  Capuron.  I 
have  also  consulted  with  advantage  the  manual  recently  published  by 
my  friend,  Dr.  Jacquemier ;  also,  the  memoirs  of  Simpson,  Tjdor  Smith, 
Depaul,  Devilliers,  &c.  I  may  be  permitted  also  to  express  publicly 
my  thanks  to  M.  Coste,  for  his  great  kindness  in  allowing  me  to  study 
his  beautiful  collection  in  the  College  of  France,  and  to  borrow  several 
figures  from  the  magnificent  work  which  he  is  now  publishing.  Lastly, 
it  will  be  seen  how  highly  I  value  the  eminently  practical  writings  of 
Madame   Lachapelle.     In  a  word,  I    have  selected   from  all   sources 


PREFACE.  IX 

whatever  bears  the  impress  of  truth.  In  the  sciences  of  observation,  a 
new  work  is  necessarily  enriched  by  the  labors  of  all  antecedent  writers  ; 
and  therefore,  its  greatest  merit  consists  in  collecting  its  scattered  ma- 
terials, and  forming  out  of  them  a  body  of  doctrine,  which  it  illustrates 
in  the  clearest  and  simplest  manner  possible.  Such  is  the  end  I  have 
endeavored  to  attain ;  and  the  medical  public,  and  students  especially, 
must  judge  whether  I  have  succeeded  in  the  attempt. 

"  But  few  quotations  have  been  made,  though  their  number  might 
have  been  greatly  increased ;  but  I  wished  to  avoid  the  charge  made 
by  most  students  against  one  of  our  best  classical  works.  However,  I 
have  felt  bound  to  refer  to  living  authors  whenever  I  have  introduced 
a  new  theory,  or  any  particular  procedure,  which  emanated  from  them ; 
and  besides,  as  the  professorate  may  be  deemed  a  mode  of  publicity,  I 
have  respected  the  right  to  the  original  ideas  which  I  have  heard 
emitted  by  Professor  Dubois;  and  his  name  will  be  found  scrupulously 
associated  with  all  the  opinions  emanating  from  him. 

"  Notwithstanding  a  spurious  copy  published  in  Belgium,  and  several 
translations  into  foreign  languages,  the  large  editions  of  the  work  first 
published  were  rapidly  exhausted.  So  favorable  a  reception  made  it 
obligatory  upon  me  to  neglect  nothing  which  could  render  this  edition 
worthy  of  the  reputation  of  its  predecessors.  I  have,  therefore,  reviewed 
and  corrected  all  parts  of  it  with  scrupulous  care." 

The  plan  of  the  present  edition  has  been  so  greatly  modified  that  it 
may  be  regarded  as  altogether  new,  the  order  followed  being  that  which 
I  long- since  adopted  for  my  course  of  lectures,  as  the  most  natural  and 
the  best.  The  chapters  are  grouped  into  eight  principal  parts.  Part 
first  is  devoted  to  the  female  organs  of  generation.  The  pelvis  is  first 
studied  by  describing  separately  each  of  its  component  parts,  afterwards 
considering  them  as  a  whole,  and  pointing  out  carefully  whatever  pecu- 
liarities it  may  present  as  to  form,  direction,  and  size ;  then  we  pass 
immediately  to  the  anatomical  description  of  the  external  and  internal 
organs  of  generation.  It  will  be  seen  that  I  have  here  profited  by  M. 
Sappey's  recent  researches  in  regard  to  the  structure  of  the  ovary,  and 
those  of  Dr.  Iielie  (of  Nantes)  in  regard  to  the  structure  of  the  uterus. 
The  physiology  of  the  genital  organs  is  now  so  intimately  connected 
with  their  anatomical  arrangement  that  it  is  impossible  to  describe 
them  fully  without  speaking  at  the  same  time  of  their  functions.  The 
phenomena  which  they  exhibit  at  certain  periods  are  also  very  properly 
regarded  as  the  preludes  of  generation,  making  their  preliminary  study 


X  PREFACE. 

indispensable  to  all  who  would  understand  the  changes  which  these 
organs  undergo  during  the  puerperal  condition. 

The  genital  apparatus  of  the  female  having  been  studied  in  the  non- 
pregnant condition,  we  examine,  in  the  second  part,  those  very  numerous 
and  important  changes  which  they  undergo  during  gestation,  and  shall 
often  have  occasion  to  quote  the  many  works  of  Robin  on  the  uterin* 
mucous  membrane,  the  decidua,  and  the  placenta.  We  afterwards 
■study  the  first  cause  of  all  of  these  changes,  to  wit,  the  foetus  and  its 
appendages,  which  are  traced  through  the  various  stages  of  their  devel- 
opment.    From  this  examination  we  deduce  the  signs  of  pregnancy. 

Having  acquired  these  preliminary  notions,  we  are  in  a  condition  to 
enter  upon  the  subject  of  labor  in  the  third  part  of  the  work.  In  the 
process  of  parturition  we  distinguish  two  orders  of  phenomena :  one 
purely  physiological  and  expressive  of  the  vital  action  called  into  play 
in  order  to  expel  the  foetus;  the  others,  purely  mechanical,  and  consti- 
tuting the  mechanism  by  which  this  expulsion  takes  place. 

We  have  given  great  latitude  to  the  description,  and  especially  to  the 
explanation  of  the  mechanism  of  natural  labor,  and  think  that  we  have 
succeeded  in  explaining  certain  facts  which,  hitherto,  had  only  been 
pointed  out.  New  views  have  also  led  us  to  describe  six  principal 
stages  in  the  mechanism  of  all  the  presentations.  After  the  labor, 
properly  so  called,  comes  the  study  of  the  delivery  of  the  after-birth, 
and  of  the  puerperal  state ;  this  part  including  afterward  the  subject 
of  the  attentions  to  be  given  to  the  woman  during  and  after  labor,  as 
also  an  article  devoted  to  apparent  death  of  new-born  children. 

I  have  also  greatly  extended  the  pathology  of  pregnancy,  to  which 
the  entire  fourth  part  is  devoted.  Chapters  entirely  new  will  be  found 
in  it  on  the  diseases  of  pregnancy,  the  alterations  to  which  the  placenta 
is  subject,  and  the  death  of  the  child  during  intra-uterine  life.  Thus, 
I  hope  that  I  have  supplied  an  omission  that  was  to  be  regretted. 

In  the  fifth  part,  which  is  devoted  to  difficult  labor,  we  treat  in 
detail  of  deformities  of  the  pelvis  and  all  other  causes  of  dystocia,  the 
way  in  which  each  operates,  their  situation  in  the  mother,  the  child  or 
its  appendages,  the  signs  whereby  their  presence  may  be  detected,  the 
indications  which  they  present,  and  the  means  of  remedying  them.  In 
the  study  of  the  accidents  which  are  liable  to  complicate  labor,  I  have 
profited  by  all  the  works  published  of  late  years,  and  in  the  account 
of  hemorrhage,  puerperal  convulsions,  and  the  indications  which  they 
present,  will  be  found  some  new  considerations.     To  fill  up  properly 


PREFACE.  XI 

the  outline  which  we  had  traced,  it  became  necessary  to  treat  carefully 
of  artificial  delivery  of  the  after-birth,  and  the  accidents  to  which  it  is 
liable. 

I  have  introduced  a  sixth  part,  devoted  to  obstetrical  therapeutics, 
which  includes  two  chapters  only :  the  first  being  devoted  to  ergot,  and 
the  second  to  the  effect  of  a  debilitating  regimen  and  a  certain  course 
of  medication  upon  the  development  of  the  child  during  intra-uterine 
life. 

The  seventh  part  comprises  a  discussion  of  the  use  of  anaesthetics  in 
labor,  an  account  of  the  use  of  the  tampon  and  of  all  the  obstetrical 
operations,  rendered  in  a  degree  of  detail  proportioned  to  the  interest 
which  attaches  to  them. 

The  eighth  and  last  part,  is  exclusively  devoted  to  the  hygiene  of 
the  child  from  birth  to  the  period  of  weaning. 

It  would  be  impossible  to  point  out  all  the  additions  which  are 
scattered  through  the  work,  but  they  are  very  many.  Everywhere 
have  I  accorded  to  the  views  of  Professors  Depaul  and  Pajot,  as  also 
to  the  views  of  all  contemporaneous  authors,  the  prominence  which 
they  deserve.  I  hope  therefore  that  this  book,  which  is,  so  to  speak, 
a  new  one,  will  be  found  to  represent  all  the  most  important  knowledge 
which  we  possess  pertaining  to  the  obstetric  art. 

TARNIER. 


CONTENTS  OF  VOLUME  I. 


PART  I. 

OF  THE  FEMALE  ORGANS  OF  GENERATION. 

PAOE 

CHAPTER   I.  — Of  the  Pelvis, 33 

Article  I.  —  Of  the  Bones  of  the  Pelvis,            .....  34 

\  1.  The  Sacrum,      ..........  34 

§2.  Coccyx, 36 

§  3.  Coxal  Bones,  or  Ossa  Innominata,     ......  37 

Article  II.  —  Articulations  of  the  Pelvis, 39 

§  1.  Articulation  of  the  Pubis,       .                   40 

§  2.  Sacro-Iliac  Articulations,   . 41 

\  3.  Sacro-Coccygeal  Articulation,         ......  42 

\  4.  Sacro-Vertebral  Symphysis,       .                   43 

\  5.  Sub-Pubic  Membrane, 44 

Article  III.  —  Of  the  Pelvis  in  general, 44 

<}  1.  External  Surface,            .........  44 

2  2.  Internal  Surface,        . .44 

\  3.   Superior  Strait,      .........  47 

\  4.  Inferior  Strait, 40 

\  5.  Cavity  of  the  Pelvis, 51 

I  6.  Base  of  the  Pelvis 53 

\  7.  Differences  of  the  Pelvis, 53 

I  8.  Uses  of  the  Pelvis, 54 

Article  IV.  —  Of  the  Pelvis  covered  by  the  Soft  Parts,          ...  54 

•CHAPTER   II. — Of  the  External  Organs  of  Generation,      ...  57 

Article  I.  —  The  Mons  Veneris,          .......  5S 

Article  II.  —  The  Vulva .  .58 

Labia  Majora,         ....                  ....  58 

Labia  Minora, 59 

Clitoris, .  60 

Vestibule, 61 

xiii 


XIV  CONTENTS. 

PAGE 

Urethra, 51 

Hymen,     .  .62 

Carunculae  Myrtiformes, 63 

Fossa  Navicularis,     .........  63 

Article  III.  —  Secretory  Apparatus  of  the  External  Genital  Organs,     .  64 

Sudoriparous  Glands,     ........  64 

Sebaceous  Glands 64 

Mucous  Glands, 61 

Vulvo-Vaginal  Gland, 65 

A&ticle  IV.  —  The  Perineum, 67 

Perineal  Floor 07 

Perineal  Body, 67 

CHAPTER   III.  —  Internal  Organs  of  Generation,          ....  68 

Article  I.  —  The  Vagina, 68 

Article  II.  —  The  Uterus, 71 

\  1.  External  Surface  of  the  Uterus, 73 

Body  of  the  Uterus 73 

Neck  of  the  Uterus, 74 

|  2.  Internal  Surface  of  the  Uterus, 76 

Cavity  of  the  Body, 76 

Cavity  of  the  Neck, 77 

|  3.  Structure  of  the  Uterus, 78 

Peculiar  Tissue,     .........  78 

Peritoneal  Membrane,         .......  78 

Mucous  Membrane,        . 79 

\  4.  Ligaments  of  the  Uterus 82 

Broad  Ligaments,            .         .                   .....  82 

Bodies  of  Rosenmliller, 82 

Round  Ligaments, 84 

Article  III.  — The  Fallopian  Tubes 85 

Article  IV.  —  The  Ovaries, 86 

\  1.  Structure  of  the  Ovaries,        .......  88 

\  2.  Ovarian  Vesicles,       .........  90 

\  3.   Human  Ovule,                                    .' 90 

CHAPTER   IV.  —  Ovulation  and  Menstruation, 93 

Article  I.  —  Modifications  of  the  Ovarian  Vesicles,    ....  93 

The  Corpus  Luteum 96 

Article  II.  —  Menstruation, 103 

CHAPTER  V.— The  Breasts 115 

Human  Milk 117 


CONTENTS. 


XV 


PART  II. 

OF  PREGNANCY. 

CHAPTER  I.  — Conception, 

CHAPTER  II.  —  Changes  in  the  Maternal  Organism, 
Article  I.  —  Changes  in  the  Uterus,  . 


§  1.  Changes  in  the  Body  of  the  Uterus, 

\  2.  Changes  in  the  Neck, 

|  3.  Changes  of  Structure,        ..... 

1.  Serous  Layer,        ...... 

2.  Mucous  Layer,  ..... 

3.  Middle  Layer,        ...... 

a.  Mad.  Boivin's  Structure,    . 

b.  Deville's  Structure,  .... 

c.  M.  Helie's  Structure, 

4.  Vascular  Apparatus,      ..... 

Article  II.  —  Properties  of  the  Uterus  (Changes  of),     . 

Sensibility  of  the  Uterus,       ..... 

Irritability,        ....... 

Contractility,  .  '      . 

Retractility,       ....... 

Article  III.  —  Changes  in  the  Parts  adjacent  to  the  Uterus, 

Article  IV.  —  Changes  in  the  Breasts, 

Article  V.  —  Anatomical  and  Functional  Changes  in  some 
concerned  in  Generation,     ..... 

§  1.  Digestion,       ....... 

\  2.  Circulation,        .         .  .... 

\  3.  Urine, 

Kyesteine,  . 

\  4.  Osteophytes  of  the  Cranial  Bones,     . 

\  5.  Pigmentary  Deposits,     ..... 


Parts  not 


page 
119 

1 25 

125 
125 
130 
13G 
130 
137 
137 
138 
139 
142 
145 

148 
148 
148 
149 
151 

152 

155 

156 
157 
157 
160 
161 
166 
166 


CHAPTER   III.  — Of  the  Decidua, 167 


Old  Theory, 
Present  Theory, 


167 
171 


CHAPTER  IV.  —  Or  the  Human  Ovum  after  Fecundation,  .        .        .       179 

Article  I. —  Changes  which  the  Ovule  undergoes  in  the  Fallopian  Tube,       180 
Disappearance  of  the  Germinal  Vesicle, 180 


XVI 


CONTENTS. 


Condensation  of  the  Vitellus,  . 

Polar  Globules,  

Vitelline  Nucleus  and  Segmentation  of  the  Vitellus, 


Article  III.  —  Of  the  Foetal  Appendages, 
2  1.  The  Allantoid  Vesicle, 
|  2.  Umbilical  Vesicle,  .... 

2  3.  The  Amnion, 

2  4.  Waters  of  the  Amnion,  (Liquor  Amnii), 
?  5.  Chorion,     ...... 


Article  IV.  —  Organs  of  Connection, 
2  i.  Placenta,        . 
2  2.  Umbilical  Cord, 


CHAPTER  V.— Of  tub  F<etus, 

Article  I.  —  The  Foetus  during  Intra-Uterine  Life 

Article  II.  —  Head  of  the  Foetus  at  Term,    . 

Article  III.  —  Position  and  Attitude  of  the  Foetus 

Article  IV.  —  Functions  of  the  Foetus, 

2  1.  Nutrition, 


2  2.  Respiration, 
2  3.  Circulation,    . 
2  1.  Innervation, 
2  5.  Secretions, 


CHAPTER  VI.  — Diagnosis  of  Pregnancy, 
Article  I.  —  Rational  Signs, 


Article 
§1. 


2  2. 
2  3. 
{4. 


II.  —  Sensible  Signs, 
The  Touch,    . 

Vaginal  Touch, 

Anal  Touch, 

Ballottement, 
Abdominal  Palpation,    . 
Active  Motions  of  the  Foetus, 
Auscultation, 

1.  Sounds  of  the  Heart, 

2.  Souffle  of  the  Cord, 

3.  Uterine  Souffle, 


CHAPTER  VII.— Twin  Pregnancy. 


page 
180 

180 
181 


Article  II.  —  Changes  undergone  by  the  Ovule  from  the  time  of  its 

Arrival  in  the  Womb  to  the  Formation  of  the  Allantoid,     .         .       182 


187 

187 
188 
190 
101 
102 

104 
104 

207 

210 
211 
217 
222 
225 
225 
229 
231 
236 
236 

237 

237 

242 
242 
243 
245 
245 
247 
250 
252 
253 
257 
258 

269 


CONTENTS.  XVI 1 

PART  III. 

OF  LABOR. 

PAGE 

CHAPTER  I.  — Causes  of  Natural  Labor, 27fi 

I  1.    Efficient  Causes, 276 

\  2.  Determining  Causes,          .         . 280 

CHAPTER   II.  —  Physiological  Phenomena  op  Labor,          .        .        .  284 

\  1.  Pain  and  Contraction, 288 

I  2.  Dilatation  of  the  Neck, 292 

§  3.  Glairy  Discharges, 293 

I  4.  Bag  of  Waters, 294 

\  5.  Duration  of  Labor 297 

\  6.  Effect  of  Labor  upon  the  Mother  and  Child,          ...  300 

CHAPTER   III.  —  Mechanical  Phenomena  op  Labor,       ....  304 

Article  I.  —  Presentations  and  Positions 304 

Article  II.  —  Presentation  of  the  Vertex,      ..'...  314 

1  1.  Causes, 314 

\  2.  Diagnosis, 315 

g  3.  Mechanism, 317 

\  4.  Inclined  or  Irregular  Presentation  of  the  Vertex,     .         .         .  331 

\  5.  Prognosis, 331 

Article  III.  —  Face  Presentation, 335 

\  1.  Causes 335 

\  2.  Diagnosis,           ..........  336 

2  3.  Mechanism,             338 

{j  4.  Inclined  or  Irregular  Presentations, 345 

\  5.  Prognosis, 345 

Article  IV.  —  Presentation  of  the  Pelvic  Extremity,     ....  347 

§  1.  Causes, 349 

\  2.  Diagnosis, 349 

g  3.  Mechanism 351 

\  4.  Prognosis, 357 

Article  V.  —  Presentation  of  the  Trunk, 361 

\  1.  Causes 362 

\  2.  Diagnosis, 363 

|  3.  Mechanism, 3C6 

Spontaneous  Version, 3G6 

Spontaneous  Evolution, 368 

I  4.   Prognosis, 371 

2 


xviii  CONTENTS. 

PAGH 

Article  VI.  —  Recapitulation  of  the  Mechanism  of  Labor  in  general,  .  371 

CHAPTER   IV.  — Twin  Labor 375 

•  CHAPTER   V.  —  Premature  and  Retarded  Labor, 377 

Article  I.  —  Premature  Labor, 377 

Article  II.  —  Retarded  Labor, '               .  379 

CHAPTER   VI.  — Natural  Delivery  of  the  Placenta,  .         .         .381 

CHAPTER  VII.  —  Attentions  to  the  Woman  and  Child  during  Labor,  388 

Article  I.  —  Attentions  to  the  Woman  during  Labor,    ....  388 

Article  II.  —  Attentions  to  the  Child  during  Labor,      ....  399 

CHAPTER   VIII.  —  Attentions  to  the  Woman  and  Child  immediately 

after  Labor, 405 

Article  I.  —  Attentions  to  the  Woman  immediately  after  Labor,  .         .  405 

Article  II.  —  Attentions  to  the  Child  immediately  after  Birth,      .        .  406 

I  1.  When  the  Child  is  healthy 40G 

\  2.  When  the  Child  is  weak  or  diseased, 409 

CHAPTER  IX.  —  Phenomena  of  the  Lying-in  State,      ....  421 

I  1.  After-pains, 429 

§  2.  Lochia, 431 

\  3.  Secretion  of  Milk 435 

CHAPTER  X.  —  Attentions  to  the  Woman  during  nER  Lying-in,         .  439 


PAET  IV. 

PATHOLOGY  OF  PKEGNANCY. 

CHAPTER   I.  —  Diseases  which  may  exist  during  Pregnancy,       .        .  443 

\  1.  Epidemic  Diseases,    ........  443 

Grippe  or  Influenza, 443 

Cholera 444 

\  2.  Endemic  Diseases, 445 

Intermittent  Fever, 445 

{ 3.  Eruptive  Fevers, ...  446 

Variola 446 


CONTENTS. 


XIX 


Scarlatina, 

Roseola, 
2  4.  Various  Sporadic  Diseases, 

Typhoid  Fever,    . 

Pneumonia,    . 

Various  Inflammations, 

Icterus, 

Syphilis,     . 

Saturnine  Intoxication, 

Phthisis,      .... 

Hysteria,  Epilepsy,  Chlorosis, 
2  5.  Surgical  Affections, 
2  6.  Hypertrophy  of  the  Thyroid  Gland, 
\  7.  Ulceration  of  the  Neck  of  the  Uterus 

CHAPTER   II.  — Diseases  of  Pregnancy, 

Article  I.  —  Lesions  of  Digestion, 
§  1.  Anorexia,       .... 
2  2.  Pica,  Pyrosis,     .... 
2  3.  Vomiting,       .... 

1.  Simple  Vomiting, 

2.  Intractable  Vomiting,    . 

3.  Treatment  of  Vomiting,     . 

a.  Medical  Treatment, 

b.  Surgical  Treatment, 
2  4.  Constipation  ;  Diarrhoea, 

Article  II.  —  Lesions  of  Respiration,    . 

Article  III.  —  Lesions  of  Circulation, 

1  1.  Plethora ;  Hydraernia, 

2  2.  Hemorrhage, 
2  3.  Varicose  Veins  ;  Hemorrhoids, 

Article  IV.  —  Lesions  of  the  Secretions  and  Excretions, 

2  1.  Ptyalism, 

2  2.  Excretion  of  Urine,  .... 

2  3.  Albuminuria;  Uraemia, 

2  4.  Dropsy  of  the  Cellular  Tissue,  . 

2  5.  Ascites, 

Article  V.  —  Lesions  of  Innervation,     . 

\  1.  Eclampsia,      .....•• 

2  2.  Vertigo  ;  Syncope, 

{3.  Various  Forms  of  Neuralgia;  Odontalgia,     . 

2  4.  Paralysis, 

2  5.  Intellectual  Disorders.     Mania,     . 


PAGE 

417 
448 
448 
448 
448 
449 
449 
451 
453 
453 
455 
455 
457 
457 

40i 

463 
4G3 
4»34 
40-1 
405 
407 
470 
470 
47-1 
477 

478 

479 
479 
486 
4S7 

488 

488 
489 
490 
500 
502 

505 

505 
505 
507 
507 
510 


CONTENTS. 


Article 

11. 

12. 

Article 

21. 
2  2. 

Article 

21. 
2  2. 
2  3. 

Article 

21. 
2  2. 
2  3. 

Article 
II. 

2  3. 

2  4. 


VI.  —  Diseases  of  the  Skin,     . 

Itching,  ...... 

Pigmentary  Spots    ..... 

VII.  —  Lesions  of  the  Pelvic  Articulations, 
Relaxation  of  the  Symphysis, 
Inflammation  of  the  Symphysis, 

VIII.  —  Diseases  of  the  Vulva  and  Vagina, 
Pruritus  of  the  Vulva,     .... 

Leucorrhcea,        ...... 

Vegetations, 

IX.  —  Abdominal  and  Uterine  Pains, 
Abdominal,  Lumbar,  and  Inguinal  Pains, 

Uterine  Pains 

Rheumatism  of  the  Uterus, 

X.  —  Displacements  of  the  Uterus,    . 

Prolapsus, 

Retroversion,       ...... 

Anteversion,    ...... 

Lateral  Obliquity, 


CHAPTER   III.  — Diseases  of  the  Ovum, 


Article  I.  —  Dropsy,       ...... 

\  1.  Dropsy  of  the  Amnion, 

\  2.  Hydrorrhcea,       ...... 

\  3.  Dropsy  of  the  Villi  of  the  Chorion,  (Hydatiform  Mol 

Article  II.  —  Lesions  of  the  Placental  Villi, 

Fibrous  Obliteration,       .... 

Article  III.  —  Effusions  of  Blood  in  the  Placenta, 
Placental  Apoplexy,       .... 


CHAPTER   IV.  —  Diseases  and  Death  of  the  Fcetus, 
\  1.  Diseases  of  the  Foetus 


\  2.  Death  of  the  Foetus, 


CHAPTER  V.  — Abortion, 

Article  I.  —  Causes,       .... 
\  1.  Causes  of  Spontaneous  Abortion, 
§  2.  Causes  of  Accidental  Abortion, 
\  3.  Causes  of  Induced  Abortion, 

Article  II.  —  Symptoms  of  Abortion, 

A  mi  n.E  III. —  Diagnosis, 


«,) 


PARE 

512 
512 
513 

514 
514 

516 

51/ 
517 
518 
519 

520 
520 

522 


524 

528 
528 
532 
539 
541 

541 

541 
541 
545 
547 

549 
55C 

552 
554 

556 

556 
558 

56C 

561 
561 
566 
567 

567 

571 


CONTEXTS.  XXI 

PAGE 

Article  IV.  —  Delivery  of  the  Placenta  in  Abortion,        .  .  575 

Article  V.  —  Prognosis, 578 

Article  VI. — Treatment, .        <,        .  579 

CHAPTER  VI.  —  Extra-Uterine  Pregnancy,  ...  .585 

Pathological  Anatomy, 591 

Symptoms, 594 

Progress, ■>  596 

Causes, 598 

Treatment, 60] 


LIST  OF  COLORED  PLATES 

AND  OTHER 

FULL   PAGE  ILLUSTRATIONS. 


PAGF 

Plate  I.  (Colored.)  Median  perpendicular  section  of  pelvis  from  front  to  back, 
showing  both  pelvic  spaces  and  the  relations  of  the  female  pelvic  organs 
to  each  other Frontispiece. 

Plate  II.     Figures  of  Uterus  at  twentieth  or  twenty-fifth  day  of  gestation,  half 

size 174 

Peate  III.  Figures  showing  the  human  ovum,  natural  size,  thirtieth  to  thirty- 
fifth  day .210 

Plate  IV.  (Colored.)  Diagram  illustrating  the  foetal  circulation  (Flint)     .         .       232 

Plate  V.  (Colored.)  Figures  showing  section  of  frozen  body  of  a  woman  during 
the  period  of  expulsion.  The  engagement  of  the  head.  Commencing 
expulsion  of  the  head,  and  the  relations  of  the  muscular  floor  of  tlie  pelvis 
to  the  presentation  at  the  last  stage  of  parturition  .....       325 

Peate  VI.     Four  figures   illustrating   occipital,  face,  brow,  and  antero-frontal 

presentation  (Olshausen) 347 

Plate  VII.     Four   figures    representing    the   different    stages  of    spontaneous 

expulsion,  and  one  figure  showing  labor  with  the  body  bent  double       .         .       371 

Plate  VIII.     Six  figures  showing  flexions  and  retroversions  of  the  uterus         .       713 

Plate  IX.     (Colored.)     Two   figures,  an   ovarian   tumor   complicating    labor. 

Longitudinal  rupture  of  the  cervix 74.'! 

Plate  X.  (Colored.)  The  blood-vessels  of  the  pelvis  seen  from  t lie  front    .         .     1025 
Plate  XI.     Vertical  and  transverse  sections  of  pelvic  organs,  showing  exuda- 
tion in  cellular  tissue,  Douglas's  pouch,  right  and  left  broad  ligaments,  etc.     1145 

Plate  XII.  External  genital  organs,  showing  difference  between  those  of  the 
virgin,  nulliparous  and  parous  women,  and  prolapse  of  anterior  wall  (cysto- 
cele),  and  of  posterior  wall  (rectocele),  with  laceration  of  perinaeum. 
(Drawn  from  life)        .         .         .         .         .         .         .         .         .         .         .1177 


LIST  OF  WOOD-CUT  ILLUSTRATIONS. 


PAGE 

Anterior  surface  of  sacrum 35 

Posterior       "       "        " 35 

"             "       "   coccyx 36 

Anterior        "        "        " " 36 

External  surface  of  the  os  innominatum 37 

rnternal        "       "     "     "            "            38 

Horizontal  section  through  the  articulation  of  the  pubis 40 

Posterior  view  of  the  articulation  of  the  pubis 40 

Pelvis  with  its  ligaments ;  the  anterior  portion  removed 42 

IVK  is  with  its  ligaments,  posterior  view 42 

The  plane  and  axis  of  the  superior  strait  and  of  the  inferior  strait        .        .        .48 

Diameters  of  the  pelvis 48 

The  plane  and  axis  of  the  inferior  strait 50 

Diameters  of  the  pelvis •         .51 

The  pelvic  excavation 52 

Pelvis  with  soft  parts  seen  from  above 55 

Position  of  the  pelvis  and  the  direction  of  its  axis  during  labor     ....  57 

External  genital  parts 58 

The  hvmen  in  the  form  of  a  crescent 62 

•       *  "         "          "         "    circle 62 

Urethral  follicles 65 

Vulvo-vaginal  gland         ............  66 

Muscles  of  the  female  perineum 67 

The  internal  genital  organs i  1 

Relative  position  of  the  pelvic  viscera 73 

Differences  in  the  uterine  neck  and  external  orifice 75 

Cavity  of  the  uterus  and  the  Fallopian  tubes 76 

Three  sections  of  the  virgin  uterus 77 

Mucous  membrane  and  tissue  of  the  uterus 80 

Bodies  of  Rosenmuller 83 

Uterus  and  Fallopian  tubes 84 

Ovary  of  female  after  puberty 87 

Section  of  ovary 89 

Ovule  or  Graafian  vesicle 90 

Nun-fecundated  human  ovule 91 

Ovary  and  Graafian  vesicle  at  highest  degree  of  development        ....  94 

Ovary  and  ruptured  vesicle 94 

Uterus  laid  open       .....         96 

Ovary  laid  open  longitudinally 97 

Corpus  luteum  (sixth  month  of  pregnancy) 100 

Lobules  of  a  mammary  gland          ..........  116 

Mammary  gland  of  human  female.        .........  117 

Section  of  neck  of  the  uterus          .        .        . 132 

(A)  Gradual  dilatation  of  the  neck  of  uterus  during  pregnancy    ....  133 

|:           »               "             u          u        u                 a            it              ....  133 

(             "               "             "           "        "                 it            tt               ....  133 

Muscular  fibres  of  the  uterus 138 

Muscular  fibres  on  anterior  face  of  womb 140 

Disposition  of  the  muscular  fibres  on  posterior  face  of  womb         ....  141 

Intercrossing  of  the  uterine  fibres 141 

xx  iv 


the  ov 


LIST    OF    ILLUSTRATIONS. 


Second  plane  of  the  anterior  muscular  layer   . 

Internal  muscular  layer 

The  nipple,  sebaceous  tubercles,  and  areola 

Section  of  womb 

The  decidua  after  the  arrival  of  the  ovum 

The  layer  of  albumen 

The  vitelline  membrane 

Fecundated  ovum 

Ovule  shortly  after  its  arrival  in  the  womb     . 
The  blastoderm 

"  "  (in  profile)      ..... 

Section  of  more  developed  ovum     .... 

Origin  and  first  traces  of  the  amnios 

The  amniotic  hoods ....... 

Amnios  almost  completed,  and  the  origin  of  the  allantois 
Rapid  progress  of  the  allantois        .... 

The  allantois  spread  over  the  whole  internal  surface  of 
Placenta  with  separate  cotyledons    .... 

The  internal  or  foetal  surface  of  the  placenta 
The  external  or  uterine  surface  of  the  placenta 
Representing,  how  the  villi  of  the  chorion  ramify 
Fragment  of  the  villi  of  the  chorion 

A  case  described  by  Benckiser 

Diameters  of  the  foetal  skull    ..... 
Position  of  child  in  the  womb  .... 

"  twins       "  .... 

Form  of  the  bag  of  waters       . 
The  head  in  the  occipito-iliac  position    . 
The  head  in  the  same  position  but  more  flexed 
The  head  in  various  degrees  of  extension 
Disengagement  of  the  head      ..... 
Mechanism  of  face  presentations      .... 
Position  of  head  when  forward  rotation  of  chin  takes  p 
Three  diagrams  showing  method  of  converting  face  into 
Presentation  of  the  breech        ..... 
The  same  after  internal  rotation       .... 
The  delivery  of  the  breech      ..... 
Another  illustration  of  the  same      .... 
The  same,  disengagement  of  the  head     . 

The  same,  the  occiput  behind 

First  position  of  right  shoulder  with  arm  hanging  dow 

The  same  position  during  the  descent 

Position  after  rotation      ...... 

The  same  position,  delivery  more  advanced    . 
Bifurcation  of  the  Fallopian  tube    .... 

Contraction  of  the  sacro-pubic  diameter  of  the  pelvis 
The  superior  strait  in  the  figure  eight  pelvis  . 
Sinking  in  of  the  anterolateral  walls  of  the  pelvis 
Pelvis  deformed  by  rachitis      ..... 

"  "         by  osteomalacia      .... 

The  oblique-oval  pelvis    ...... 

Skeleton  deformed  by  rachitis 

"  "         by  flexure  of  the  vertebral  column 

Baudelocque's  callipers    ...... 


ice 
ver 


tex  presentations 


xxv 

PAGE 

14.", 
144 
156 
168 
169 
181 
181 
181 
182 
183 
183 
184 
184 
185 
185 
186 
1ST 
195 
196 
196 
202 
204 
209 
220 
223 
270 
295 
317 
319 
322 
;>-2r> 
338 
.",4(1 
347 
352 
353 
353 
354 
356 
.">">7 
369 
369 
370 
370 
,  600 
.  621 
,  621 
.  623 
.  629 
.  629 
.  630 
.  650 
.  650 
.  654 


XXVi  LIST    OF    ILLUSTRATIONS. 

PAGE 

Hue  vet's  pelvimeter ,        .         ,         .         .657 

Mensuration  of  the  symphysis  pubis        .........  658 

Huevet's  pelvimeter  as  a  pair  of  callipers 659 

A  simple  pair  of  callipers 660 

Mode  of  using  the  finger 664 

Tumor  complicating  labor        .        ...        .        .        .        .        .        .        .        .'  70'.) 

Section  of  a  fibrous  tumor        ...........  722 

Vaginal  cystocele     .............  729 

Right  posterior  occipito-iliac  position  complicated  by  the  cord       ....  829 

The  left  occipito-iliac  position 841 

"       posterior  tnento-iliac  position     .........  852 

Oval  shaped  tumors  between  the  thighs 861 

Illustrating  Jacquemier's  case  of  twins 865 

Hour-glass  contraction  of  womb 873 

Mode  of  dilating  the  strictured  part  of  womb 873 

"       breaking  up  the  adhesions  of  the  placenta 878 

Pushing  up  the  head  into  the  left  iliac  fossa 941 

Version  by  drawing  down  the  feet 942 

Delivery  of  the  posterior  arm .        ..........  945 

Mode  of  flexing  the  head 951 

"        rotating  the  face 951 

I'sim;  the  blunt  hook  in  breech  positions 955 

Introduction  of  the  hand  in  second  position  of  the  right  shoulder .        .         .         .  956 

Mode  of  seizing  the  feet  in  the  same  position 956 

"     second  position  of  left  shoulder      .         .        .         .  957 

The  male  branch  of  the  forceps 961 

The  female  branch 961 

The  forceps  locked 961 

Tarnier's  forceps        ........           ....  963 

Wells'  axis-traction  attachment  applied  to  Elliot's  forceps          ....  963 

Simpson's  forceps 964 

Hodge's  forceps 964 

Introduction  of  first  branch  of  forceps        ....          ....  967 

"              second  branch 968 

The  forceps  applied  and  locked        ..........  969 

Forceps  applied  on  the  child's  head 972 

Application  of  the  forceps  in  right  posterior  occipito-iliac  position        .        .        .  '.'73 

Forceps  applied  and  locked  in  the  left  transverse  occipital-iliac  position        .        .  976 

"             "             ''             "             "      anterior  mento-iliac  position        .         .         .  981 

The  same  in  the  mentoposterior  position 981 

Application  of  forceps  when  the  head  is  retained,  only 984 

Using  the  lever  to  pull  down  the  occiput 996 

Method  of  dilating  the  os  uteri 1012 

(A)  Intra-uterine  dilator 1017 

(B)  "          "           " 1017 

(C)  "          "            " 1017 

Smellie's  scissors  closed 1041 

Tin- same  opened 1 041 

Mode  of  using  Smellie's  scissors 1041 

Cephalotome  closed 1042 

The  same  opened 1042 

Incising  the  cranium  with  the  cephalotome    ....                 ...  1042 

The  embryotomy  or  cephalotribe  forceps  (Baudelocque's)            ....  1045 

Lusk's  cephalotribe 1045 


LIST  OF   ILLUSTRATIONS.  XXV11 

PAGE 

The  same  applied  and  locked 1046 

The  cranioclast 1054 

Mode  of  using  the  blunt  hook 1059 

Binder  for  compression  of  the  mammae  ........  1078 

"  "  "  "  1078 

"*  "  "  "  1078 

Position  of  hands  in  palpation  of  the  abdomen  (Munde) 1101 

"  "  "  at  the  beginning  of  the  examination  of  the  pelvic 

excavation  (Pinard)        .....   1105 
The  hands  exploring  the  excavation — the  right  hand  arrested  by  the  brow  on  the 

right  side  (Pinard)         ...........   HOG 

Position  of  the  hands  and  direction  of  the  pressure  in  external  version,  when  the 

position  is  oblique  (Pinard)  ..........   1113 

Position  of  the  hands  and  direction  of  the  pressure  in  external  version,  when  the 

position  is  longitudinal  (Pinard) 1114 

Munde' s  placental  curette.     Length  of  instrument,  16/r ;  width  of  loop,  \"         .  1137 
Showing  degrees  of  partial  laceration  (Munde) 1159 

"   '  "  complete  laceration  (Munde') 1159 

Wire  twister  (Munde") 1161 

Sim's  shield, 1161 

"  Crutch  "  for  bending  wire  sutures,     ...  .....   1161 


CAZEAVX  AND  TARJVIER. 


THE  THEORY  AND  PRACTICE 


OP 


OBSTETKICS. 


PART  I. 
OF  THE  FEMALE  ORGANS  OF  GENERATION 

rpHE  female  organs  subservient  to  generation  are:  the  ovaries,  the  prin- 
X  cipal  function  of  which  is  the  secretion  of  the  ovule  or  female  germ ; 
the  Fallopian  tubes,  designed  to  receive  the  ovule,  and  conduct  it  into  the 
cavity  of  the  uterus ;  the  uterus,  a  kind  of  receptacle,  whose  office  it  is  to 
contain  the  fecundated  germ  during  its  period  of  development,  and  to 
expel  it  immediately  afterward ;  finally,  the  vagina,  a  membranous  canal 
extending  from  the  neck  of  the  uterus  to  the  external  genital  parts.  Most 
of  these  organs  are  situated  within  a  large  cavity,  the  walls  of  which  are 
composed  of  bones  and  soft  parts ;  the  cavity  is  termed  the  cavity  of  the 
pelvis,  or  pelvic  cavity.  On  account  of  the  importance  of  the  pelvis  as  an 
organ  both  of  protection  and  transmission,  we  shall,  with  it,  begin  the  study 
of  the  organs  of  generation. 


CHAPTER    I. 

OF  THE   PELVIS. 

The  bnsin,  in  Latin,  pelvis,  is  a  large,  irregular,  bony  cavity,  a  sort  of 
curved  canal,  which  terminates  the  trunk  interiorly,  and  sustains  it  by  its 
posterior  part.  It  is  placed  directly  upon  the  lower  extremities,  which 
afford  it  points  of  support,  and  to  which,  in  the  erect  posture,  it  transmits 
the  weight  of  the  upper  portions  of  the  body.  Its  position  in  an  adult  of 
ordinary  stature  is,  in  general,  about  the  central  part  of  the  whole  trunk. 
In  the  infant  at  term,  and  more  especially  during  the  intra-uterine  life,  it 
is  much  below  this  point;  and  at  a  certain  period  of  foetal  existence,  when 
the  lower  extremities  resemble  as  yet  but  little  nipples,  it  even  occupies 
the  inferior  portion  of  the  body.  Especially  should  the  accoucheur  study 
«  33 


34  FEMALE  ORGANS  OF  GENERATION. 

the  pelvis  in  it?  totality  and  in  its  relations  with  the  great  function  which 
it  subserves.  Now  as  the  best  way  of  understanding  a  whole  is  to  decom- 
pose it,  and  study  separately  its  constituent  parts,  we  shall  proceed  at  once 
to  consider  individually  the  bones  which  enter  into  the  composition  of  the 
pelvis. 

ARTICLE    I. 

BONES   OF   THE   PELVIS. 

The  bones  which  together  constitute  the  pelvis  are:  the  sacrum,  ant  the 
coccyx,  both  placed  behind  and  on  the  median  line,  and  the  ossa  innominata 
or  coxal  bones.  These  last  are  in  pairs,  being  situated  at  the  sides  and 
articulating  with  each  other  in  front. 

§  1.  Of  the  Sacrum. 

This  is  a  symmetrical,  triangular  bone,  which  is  curved  forward  at  ita 
lower  part,  and  is  placed  at  the  posterior  part  of  the  pelvis,  where  it  appears 
like  a  wedge,  forced  in  between  the  two  ossa  innominata,  immediately  below 
the  vertebral  column,  and  directly  above  the  coccyx.  It  is  traversed  longi- 
tudinally by  the  sacral  canal  (a  continuation  of  the  vertebral  canal),  and. 
relatively  to  the  axis  of  the  body,  it  is  directed  from  above  downwards, 
and  from  before  backwards;  hence  the  column  represented  by  it  forms  an 
obtuse  angle  with  the  lumbar  vertebrce,  being  salient  in  front,  and  receding 
behind.  This  point  is  called  the  promontory,  or  the  sacro-vertebral  angle. 
Besides  this  direction,  the  sacrum  is  curved  upon  itself  from  behind  for- 
wards, so  as  to  present  an  anterior  concavity,  the  hollow  of  the  sacrum  : 
this  curvature  is  generally  much  more  marked  in  the  female  than  in  the 
male. 

Anatomists  describe  the  bone  as  having  two  faces,  two  borders,  a  base, 
and  an  apex. 

1.  The  spinal,  or  posterior  face,  is  convex,  rough,  and  very  irregular,  pre- 
senting on  the  median  line  three,  four,  or  five  prominences,  the  longest  of 
which  are  above,  and  continuous  with  the  ridge  formed  by  the  series  of 
spinous  processes  of  the  vertebra? ;  lower  down,  the  sacral  canal  is  terminated 
as  a  triangular  gutter,  being  bounded  laterally  by  two  tubercles,  caPled  the 
cornua  of  the  sacrum;  upon  each  side  of,  and  close  to  the  median  line,  a 
large  furrow  exists,  at  the  bottom  of  which  the  four  posterior  sacral 
foramina  are  seen,  communicating  with  the  vertebral  canal,  and  serving 
to  transmit  the  nerves  of  the  same  name.  Outside  of  these  foramina  Ave 
find  a  series  of  elevations,  apparently  analogous  to  the  transverse  processes 
of  the  vertebra?;  and  above  them  two  irregular  fossa?,  into  which  the  pos- 
terior sacro-iliac  ligaments  are  inserted. 

2.  The  pelvic,  or  anterior  face,  is  smooth  and  concave,  and  is  traversed 
by  four  prominent  transverse  lines,  the  remnants  of  the  sutures  between 
the  different  pieces  that  composed  the  bone  in  early  infancy,  and  which 
served  to  separate  some  superficial,  transverse,  and  quadrilateral  grooves 
found  there,  from  each  other.     Sometimes  the  first  of  these  prominent  lines 


OF    THE    PELVIS.  35 

is  so  well  marked  as  to  be  mistaken,  when  practising  the  touch,  for  the 
sacro-vertebral  angle. 

The  anterior  sacral  foramina,  four  in  number,  are  found  nearer  the  lateral 
margins;  they  communicate  with  the  sacral  canal,  and  transmit  the  anterior 
branches  of  the  nerves  of  the  same  name.  Beyond  the  foramina  is  an 
unequal  surface  for  the  attachment  of  the  pyramidal  muscles. 

3.  The  borders  of  the  sacrum  may  be  divided  into  two  portions.  1.  Tht 
superior,  being  very  thick,  presents,  on  its  anterior  half,  a  semilunar 
articular  facet  for  joining  with  the  coxal  bone,  and  on  its  posterior  part 
an  excavation,  and  some  rough  projections  for  the  attachment  of  the  sacro- 
iliac ligaments.  The  other,  or  inferior  portion,  is  quite  thin,  and  is 
occupied  by  the  insertion  of  the  sacro-sciatic  ligaments. 

4.  The  base  is  directed  upwardly  and  a  little  in  front,  and  has  its  greatest 
diameter  transversely.  An  oval  facet,  more  or  less  inclined  backwards, 
surmounts  it  at  the  middle,  whereby  the  bone  is  articulated  with  the  last 
lumbar  vertebra.  Upon  each  side  is  seen  a  smooth  surface,  which  is  con- 
cave transversely,  and  convex  from  before  backwards.  These  surfaces 
incline  forwards  and  are  continuous  with  the  iliac  fossa?,  being  covered,  in 
the  recent  subject,  by  the  anterior  sacro-iliac  ligaments.  They  are  sepa- 
rated from  the  anterior  face  of  the  sacrum  by  a  rounded  border,  which 
forms,  as  we  shall  hereafter  learn,  the  posterior  part  of  the  superior  strait. 
The  two  surfaces  constitute  the  %vings  of  the  sacrum.  Behind,  are  found 
the  upper  orifice  of  the  sacral  canal,  and  the  two  articular  processes  of  the 
first  piece  of  the  sacrum. 

5.  The  apex  of  the  sacrum  is-  directed  downwards,  and  a  little  back- 
wards; presenting  an  oval  facet  for  the  articulation  of  the  coccyx. 

6.  The  sacral  canal,  hollowed  out  in  the  thickness  of  the  bone,  is  the 
termination  of  the  vertebral  canal ;  being  triangular  and  broad  superiorly, 
it  becomes  narrow  and  flattened  at  its  inferior  part,  where  it  degenerates 
into  a  gutter,  that  is  converted  into  a  canal  by  the  ligaments.  This  lodges 
the  sacral  nerves,  and  communicates  both  with  the  anterior  and  the  pos- 
terior sacral  foramina. 


A--:, 


Anterior  snrfai  :e  of  the  sacrum.  Posterior  surface  of  (lie  sacrum. 

Fto.  1.    A.  Ala  or  wings  of  the  sacrum.    B.  Articular  processes.    C.  Anterior  sacral  foramina.    E.  rotate 
•»f  attachment  of  the  ri<;lit  pyramidal  musclo. 
Fin  2.    A    Ridge  formed  by  the  spinous  pi  occsses.    1!.  Posterior  sacral  foramina.    V>.  Articular  processes. 

The  sacrum,  although  quite  thick,  is  a  very  light  and  spongy  bone. 
Besides,  it  is  pierced  by  a  great  number  of  foramina,  and  traversed  by  -i 
central  cavity,  which  serve  to  diminish  its  weight  still  more. 


36  FEMALE  ORGANS  OF  GENERATION. 

It  is  formed  of  five  principal  pieces  (false  sacral  vertebra?),  sometimes  of 
six,  and  in  one  case,  seven  •were  observed  (Pauw).  In  Soemmering's 
cabinet  are  tbree  specimens  which  present  but  four  pieces. 

The  development  of  the  sacrum  is  analogous  to  that  of  the  vertebrae,  and 
takes  place  from  thirty-four  or  thirty-five  points  of  ossification,  arranged  in 
the  following  manner: 

1.  Five  of  them,  placed  one  over  the  other,  occupy  the  anterior  and 
middle  parts.  2.  In  each  of  the  interspaces  which  separate  these,  two 
small  osseous  lamina?  are  developed  some  time  after  birth,  which  seem  to 
form  their  articular  surfaces.  3.  Ten  are  situated  in  front  and  upon  each 
side  of  the  latter,  that  is,  one  for  each  lateral  portion  of  the  four  or  five 
primitive  bones.  4.  And  behind  them  six  others  are  developed,  between 
which:  5.  There  appear  three  or  four  that  correspond  with  the  spinous 
processes,  or  their  lamina?;  and  6.  Lastly,  there  is  one  upon  each  side  above 
the  iliac  surface,  for  the  articular  facet. 

§  2.  The  Coccyx. 

This  name  is  given  to  an  assemblage  of  three  or  four,  occasionally  five 
little  bones,  united  with  each  other  on  the  median  line  of  the  body,  and 
apparently  suspended  at  the  point  of  the  sacrum,  of  which,  indeed,  they 
appear  to  be  only  a  movable  appendage,  continuing  its  line  of  curvature 
forwards. 

Fio.  3.  Fio.  4. 

A.  A 


Posterior  surface  of  the  coccyx.  Anterior  surface  of  the  coccyx. 

Fio.  3.    A.  Cornua  of  the  coccyx.    B.  Apex.  Fio.  4.     A.  Cornua  of  the  coccyx.    B.  Apex. 

M.  Cruveilhier  declares  that  he  has  known  it,  in  some  cases,  to  form  a 
right  angle  or  even  an  acute  one  with  the  sacrum.  As  a  whole,  the  coccyx 
represents  a  triangular  and  symmetrical  bone. 

1.  Its  spinal,  or  posterior  face,  is  convex  and  irregular,  and  is  only 
separated  from  the  skin  by  the  posterior  sacro-coccygeal  ligament. 

2.  Its  pelvic,  or  anterior  face,  is  smooth  and  slightly  concave,  and  lies  in 
contact  with  the  termination  of  the  rectum,  which  rests  upon  it.  Like  the 
preceding  bone,  it  is  marked  by  certain  transverse  grooves,  corresponding 
with  the  intervals  which  had,  for  a  long  period,  separated  its  different  pieces. 

3.  Its  two  lateral  borders  are  quite  irregular,  and  are  occupied  by  the 
attachments  of  the  anterior  sacro-sciatic  ligaments,  and  the  ischio-coccygeal 
muscles. 

4.  Its  slightly  concave  base  presents,  above,  an  oval  surface,  which 
articulates  with  the  apex  of  the  sacrum,  and  behind,  two  little  tubercles 
called  the  cornua  of  the  coccyx. 

5.  The.  apex  is  rounded,  irregular,  and  sometimes  bifurcated,  affording 
attachment  to  the  levator  ani  muscle. 

The  coccyx  is  developed  from  four  or  five  centres  of  ossificate  >n,  that  is, 
one  for  each  of  its  parts. 


of  the   pelvis.  37 

§  3.  The  Coxal  Bone,  Haunch  Bone,  or  Os  Innominatum. 

This  is  a  non-symmetrical,  quadrilateral  bone,  curved  upon  itself,  as  if 
twisted  in  two  different  directions,  contracted  in  its  middle,  and  of  a  verv 
irregular  figure.  The  pair  occupy  the  lateral  and  anterior  parts  of  the 
pelvis.  It  presents  an  internal  and  external  face,  and  four  borders,  for 
our  consideration. 

1.  The  external,  or  femoral  surface,  is  turned  outwards,  backwards,  and 
downwards,  at  its  superior  part,  while  inferiorly,  it  looks  forward. 

At  its  superior  and  posterior  portion  is  seen  an  unequal,  narrow,  and 
convex  surface,  affording  origin  to  the  gluteus  maximus  muscle,  and  ter- 
minated below  by  a  slightly  elevated  circular  ridge,  called  the  superior 
curved  line.  Beneath  this,  there  is  a  larger  surface,  which  is  concave 
behind,  narrowed  in  front  for  the  insertion  of  the  gluteus  medius  muscle, 
and  bounded  by  a  slight  ridge  below,  called  the  inferior  curved  line;  still 
lower,  there  is  a  third  extensive  and  convex  surface,  serving  for  the  attach- 
ment of  the  gluteus  minimus  muscle.  All  that  portion  of  the  femoral  face 
just  described  forms  a  large  fossa,  alternately  concave  and  convex,  bearing 
the  name  of  the  external  iliac  fossa. 

Towards  the  front,  the  external  face  presents  the  cotyloid  cavity  or  the 
acetabulum,  at  its  superior  part;  and  a  little  more  in  advance  and  below, 
the  sub-pubic,  or  obturator  foramen.  This  opening  is  triangular,  with 
rounded  angles;  its  long  diameter  is  inclined  downwards  and  outwards, 
and  its  circumference  is  sharp  and  irregular,  presenting  above  a  groove, 
directed  obliquely  from  behind  forwards  and  from  without  inwards,  through 
which  the  obturator  vessels  and  nerves  pass  out.  A  fibrous  membrane  that 
subtends  the  foramen  is  attached  to  its  periphery,  except  in  the  immediate 
vicinity  of  the  groove. 

Upon  the  upper  side  of  the  obturator  foramen,  between  it  and  the  median 
line,  there  is  a  concave  or  nearly  plane  surface  for  the  origin  of  several 
muscles. 


External  surface  of  the  os  innominatum. 
A.  External  iliac  fossa.     B.  Crest  of  the  ilium.     C.  Anterior  superior  spine  of  the  ilium.     1).  Anterior  in- 
ferior spine  of  the  ilium.    K.  Horizontal  branch  of  the  pubis.    K.  Posterior  superior  spine  of  the  ilium 
0.  Posterior  inferior  spine  of  the  ilium.    11.  Cotyloid  cavity.    I.  Ischium.    K.  Sub-pubicor  obturator  foramen 
M.  Iscliiopubic  ramus.    C.  Descending  branch  of  the  pubis. 


38 


F EM ALE    ORGANS    OF    GENERATION. 


Fio.  6. 


2.  The  abdominal,  or  internal  face,  is  directed  forwards  at  its  uppei  part. 
and  backwards  at  the  lower.  It  may  be  divided  into  two  portions,  the 
superior  of  which  is  characterized  by  a  large  excavation,  called  the  internal 
Hide  fossa,  by  a  semilunar  articular  surface  found  just  behind  this  fossa, 
and  called  the  auricular  facet,  and  still  more  posteriorly,  by  some  rugosities, 
analogous  to  those  found  on  the  articular  faces  of  the  sacrum. 

The  superior  portion  is  terminated  below  by  a  large,  rounded,  and  con- 
cave line,  which  separates  it  from  the  other  moiety.  The  latter,  or  inferior 
portion,  presents  behind  a  nearly  triangular  plane  surface,  which  corre- 
sponds to  the  cotyloid  cavity  and  to  the  body  of  the  ischium;  near  its 
middle,  we  find  the  obturator  foramen,  and  in  front,  the  internal  face  of 
the  pubis  and  of  the  ischio-pubic  ramus. 

3.  Borders.  These  are  four  in  number. 
The  posterior  one  has  a  very  irregular 
shape,  being  oblique  from  above  down- 
wards, and  from  without  inwards.  The 
posterior  superior  spinous  process  is  found 
at  its  junction  with  the  superior  border. 
This  prominent,  well-marked  eminence  is 
separated  by  a  rough  margin  from  another 
though  less  voluminous  one,  called  the 
posterior  inferior  spinous  process. 

Below  this  last  apophysis,  the  student 
will  observe  a  very  deep  notch,  which  con- 
tributes to  the  formation  of  the  great  sciatic 
foramen,  and  is  terminated  below  by  a 
triangular,  pointed  projection,  bearing  the 
title  of  the  spine  of  the  ischium.  This  pro- 
cess is  more  or  less  prominent  in  different 
individuals,  and  is  sometimes  directed  in- 
wards. A  groove  is  seen  just  beneath  it, 
in  which  the  tendon  of  the  obturator  in- 
ternus  muscle  plays;  this  groove  is  a  part 
of  the  lesser  sciatic  notch ;  and  lastly,  this 
border  terminates  at  the  tuberosity  of  the  ischium. 

The  anterior  border  is  concave,  oblique  above,  and  nearly  horizontal  in 
front.  The  anterior  superior  spinous  process  is  formed  by  its  union  with  the 
superior  border.  A  considerable  depression  exists  under  this  apophysis, 
which  separates  it  from  another  one,  called  the  anterior  inferior  spinous 
process.  Then  we  find  a  groove  just  under  this  elevation,  for  the  gliding 
of  the  conjoint  tendon  of  the  psoas  magnus  and  the  iliacus  internus  muscles; 
which  groove  is  bounded,  in  front  and  below,  by  the  ilio-pectineal  eminence. 
And  lastly,  the  border  is  terminated  by  a  triangular  horizontal  surface, 
which  is  directed  downwards  and  forwards,  and  is  broader  externally  than 
internally,  and  by  the  spine  and  angle  of  the  pubis. 

The  superior  border  or  crest  of  the  ilium  is  thick,  convex,  and  inclined 
outwauls,  excepting  at  its  posterior  part,  where  it  looks  slightly  inwards— 


Internal  surface  of  the  right  os  innomiimtum. 
A.  Internal  iliac  fossa.  B.  Anterior  superior 
spinous  procesu  of  the  ilium.  C.  Crest  of  the 
ilium.  D.  Posterior  superior  spinous  process 
of  the  ilium.  K.  Posterior  inferior  spinous 
process  of  the  ilium.  F.  Articular  surface. 
U  Spine  of  the  ischium.  H.  Tuberosity  of  the 
ischium.  I.  Sub-pubic  or  obturator  foramen. 
K.  Ischio-pubic  ramus.  M.  Ilio-pectineal 
eminence.    N.  Spine  of  the  pubis. 


OF     THE     PELVIS  39 

being  twisted,  in  its  course,  somewhat  like  an  italic/.  Anatomists  have 
subdivided  it  into  the  external  and  internal  lips,  and  the  inlervening  space. 
The  anterior  superior  spinous  process  bounds  it  in  front,  and  the  posterior 
superior  one  behind. 

The  inferior  border  is  shorter  than  either  of  the  others;  it  presents,  how- 
ever, three  parts  for  study.  There  is  an  oval  surface  above,  for  articulating 
with  its  fellow  of  the  opposite  side,  forming  the  symphysis;  below,  it  is 
terminated  by  the  tuberosity  of  the  ischium,  and  in  the  middle,  we  find  the 
ischio-pubic  ramus;  this  is  a  sharp  ridge,  formed  superiorly  by  the  descend- 
ing branch  of  the  pubis,  and  inferiorly  by  the  ascending  portion  of  the 
ischium. 

The  coxal  bone  is  developed  from  the  principal  centres  of  ossification, 
which  appear  at  the  same  time  in  the  iliac  fossa,  the  tuberosity  of  the 
ischium,  and  in  the  pubis.  Owing  to  this  mode  of  growth,  it  has  been 
customary  to  divide  the  os  innominatum  into  three  portions:  the  superior 
one,  styled  the  ilium,  forms,  in  a  great  measure,  the  contour  and  prominence 
of  the  hip;  t\\&  pubis,  being  anterior,  supports  the  genital  organs;  and  the 
inferior  one,  which  sustains  the  body  when  seated,  is  named  the  ischium. 

Several  years  after  birth,  an  osseous  lamina  resting  upon  the  superior 
border  of  the  bone,  is  developed  to  form  the  iliac  crest,  whilst  a  similar 
layer  embraces  the  tuberosity  of  the  ischium,  and  extends  to  its  ramus ;  at 
the  same  time,  a  third  centre  of  ossification  appears  for  the  anterior  inferior 
spinous  process  of  the  ilium,  and  a  fourth  forms  the  angle  of  the  pubis. 

ARTICLE    II. 

ARTICULATIONS   OF   THE   PELVIS. 

[The  four  bones  just  described  are  united  by  four  articulations  peculiar  to  the 
pelvis ;  one  in  front  for  the  two  pubic  bones,  two  behind  for  the  iliac  bones  and  the 
sacrum,  and  that  of  the  coccyx  with  the  sacrum.  All  these  articulations  are 
usually  termed  symphyses ;  thus  the  articulation  of  the  two  pubic  bones  is  styled  the 
pubic  symphysis,  the  junction  of  the  iliac  bone  with  the  sacrum  is  called  the  sacro- 
iliac symphysis,  and  the  connection  of  the  sacrum  and  coccyx  the  sacro-coccygeal 
symphysis. 

It  should  be  observed,  however,  that  the  symphyses  or  am  phi  arthroses  are 
characterized  by  fiat  articular  surfaces,  united  by  a  layer  of  fibrous  tissue  which 
allows  a  bending  motion  without  any  sliding  of  the  bones  upon  each  other.  Now 
this  sliding  motion  exists  in  the  pelvic  articulations  of  the  female.  It  is,  there- 
fore, a  mistake  to  classify  them  amongst  the  amphiarthroses,  and  only  by  an  abuse 
of  language  can  they  continue  to  be  called  symphyses.  Lenoir's  researches  prove 
that  some  anatomists  were  near  the  truth  in  considering  them  as  arthrodia.  In 
twenty-two  female  subjects  between  the  ages  of  eighteen  and  thirty-five  years, 
Lenoir  found  that  the  four  pelvic  articulations  are  formed  by  the  ('(intact  of  sur- 
faces covered  with  cartilage  and  lined  with  synovial  membranes;  they  present, 
therefore,  all  the  characteristics  of  arthrodia,  and  have  a  simple,  sliding  motion. 

To  the  four  articulations  proper,  of  the  pelvis,  it  is  well  to  add  in  this  connection, 
the  articulation  of  the  sacrum  with  the  spinal  column.  Here  we  have  really  on« 
of  the  amphiarthroses  or  symphyses. 

The  description  of  the  sub-pubic  ligament  completes  the  history  of  the  liga- 
mentous connections  of  the  pelvis. J 


40 


FEMALE    ORGANS    OF    GENERATION. 


§  1.  Articulation  of  the  Pubis. 

This  articulation  is  formed  by  the  approximation  of  the  oval  surfaces 
occupying  the  upper  part  of  the  lower  border  of  the  coxal  bones.  These 
surfaces  are  slightly  convex  and  unequal,  and  are  covered  with  a  cartila- 
ginous lamina  which  fills  up  the  inequalities.  The  convex  shape  and  the 
direction  of  their  faces  are  such,  that  they  only  come  into  contact  for  an 
inconsiderable  extent  at  their  internal  or  posterior  part,  and  hence  they 
leave  above,  in  front,  and  below,  an  open  space,  which  is  the  more  con- 
siderable, in  proportion  to  the  distance  from  the  centre  of  the  joint.  The 
articulating  surface  of  the  two  cartilages  is  a  little  facet,  about  six  or  eight 
lines  in  its  vertical  diameter,  by  two  or  three  in  its  transverse  one.  This 
facet  is  smooth,  and  furnished  with  a  synovial  membrane,  which  is  the 
more  lubricated  Avith  synovia  .as  the  female  approaches  the  period  of  labor. 
A  considerable  thickness  of  the  interpubic  ligament  fills  up  the  interval 
which  exists  between  the  other  points  of  these  articular  surfaces. 

This  interpubic  ligament  is  formed  of  a  very  dense  fibrous  substance.  It 
has  the  form  of  a  wedge,  with  the  point  forced  down  between  the  bones  and 
the  sides  adhering  to  the  rough  surfaces  fronting  the  articulation.  Two 
planes  of  fibres  are  discoverable  in  it;  the  deeper  ones,  which  pass  from  one 
iliac  bone  to  the  other,  and  are  shorter  in  proportion  to  their  depth,  are 
crossed,  and  disposed  in  several  layers.  They  constitute  the  interpubic  liga- 
ment properly  so  called.  The  others,  which  are  more  superficial,  are 
parallel,  and  pass  obliquely  from  within  outwards  and  from  above  down- 
wards. Beginning  at  the  upper  part  of  the  articulation  they  spread  in 
descending,  until  they  are  finally  divided  into  two  bundles,  which  become 
lost  in  front  of  the  branches  of  the  pubic  arch  by  mingling  with  the  peri- 
osteum of  the  bones  and  the  tendons  of  the  muscles  inserted  in  the  vicinity. 
These  form  the  anterior  pubic  ligament. 

The  uppermost  portion  of  the  anterior  pubic  ligament  seems  to  take  its 
origin  in  the  fibrous  cord  Avhich  is  inserted  on  the  spine  of  the  pubis,  and 
which  cushions,  so  to  speak,  the  upper  edge  of  that  bone,  in  such  a  way  as 
to  efface  its  inequalities.     It  constitutes  the  superior  pubic  ligament. 

Lastly,  at  its  lowest  part,  the  anterior  pubic  ligament  assumes  the  form 
of  a  thick  triangular  bundle  occupying  the  summit  of  the  pubic  arch,  and 
fixed  by  its  lateral  edges  to  the  upper  and  internal  part  of  the  two  branches 
thereof.     This  ligament,  called  the  triangular,  or  sub-pubic  ligament,  pre- 

Fio.  7.  Fin.  8. 


Hoi  izontal  section  through  the  articulation  of  the  pubis.        Posterior  view  of  the  articulation  of  the  pubis. 
Fig.  7.    A.  Synovial  Diembrane.    B.  Articular  cartilages.    C.  Inter-pubic  ligament.    D.  Section  oft  lie  bones 
Fig.  8.     A.  Posterior  projecting  pad.     15.  Sub-pubic  ligament.    C.  Section  of  horizontal  branch  of  pubis 

!).  Section  of  ischiopab5"  ramus. 


OF     THE     PELVIS.  41 

senl3  a  rounded  base,  which  completes  the  arch  of  the  pubes  by  giving  it  a 
regular  curve  calculated  to  facilitate  the  exit  of  the  foetus. 

Thus,  we  have  three  anterior  pubic  ligaments,  a  superior  pubic  and  a 
3ub-pubic  ligament,  all  of  them  representing  a  spreading  out  of  the  inter- 
osseous ligament.  Behind  the  S)rmphysis,  the  fibro-cartilaginous  substance 
forms  a  sort  of  projecting  pad,  which  occupies  the  middle  part  only,  and 
disappears  from  above  downwards. 

Finally,  the  ligamentous  arrangement  of  the  articulation  is  completed 
by  the  posterior  pubic  ligament,  composed  of  fibres  extending  transversely 
from  one  pubis  to  the  other,  above  the  projection  just  noticed.  This  liga- 
ment, which  is  very  thin,  and  of  moderate  strength,  forms  the  posterior 
lining  of  the  synovial  membrane. 

§  2.  Sacroiliac  Articulations. 

This  articulation  is  formed  by  the  junction  of  the  semilunar  facets,  which 
were  pointed  out  in  describing  the  border  of  the  sacrum  and  the  internal 
face  of  the  ossa  ilia. 

Both  these  facets  are  covered  with  a  diarthrodial  cartilage,  which  is 
closely  adapted  to  the  inequalities  they  present;  that,  however,  which  per- 
tains to  the  sacrum,  being  always  much  thicker  than  the  layer  which 
belongs  to  the  iliac  bones.  The  latter  is  so  thin,  that  its  existence  has  been 
denied.  These  cartilages  are  covered  with  a  synovial  membrane,  which 
secretes  quite  abundantly  a  viscid  and  transparent  synovia.  But,  when 
the  female  has  passed  the  prime  of  life,  this  fluid  often  concretes,  and 
becomes  disposed  in  isolated  flakes  upon  the  articular  surfaces,  —  a  fact 
which  has  caused  its  true  nature  to  be  misunderstood. 

A  very  limited  sliding  motion  is  all  of  which  this  articulation  is  suscep- 
tible.    The  bones  are  held  together  by  the  following  ligaments : 

1.  The  posterior,  or  great  sacro-sciatic  ligament,  is  found  at  the  posterior 
inferior  pai-t  of  the  pelvis.  It  is  triangular,  thin,  flattened,  and  narrower 
in  the  middle  than  at  the  extremities.  It  arises  by  a  large  base  from  the 
posterior  inferior  spinous  process  of  the  ilium,  the  sacro-spinous  ligament, 
the  last  of  the  posterior  tubercles  of  the  sacrum,  and  from  the  inferior  part 
of  the  margin  of  this  bone  and  border  of  the  coccyx,  and  running  outwards, 
downwards,  and  a  little  forwards,  is  inserted  into  the  tuberosity  of  the 
ischium.  Its  fibres  are  arranged  in  such  a  way,  that  the  internal  ones 
cross  the  external  about  their  middle. 

2.  The  lesser  sacro-sciatic  ligament  is  smaller  than  the  preceding,  though 
nearly  of  the  same  form,  and  situated  more  in  front.  Within,  it  is  broad, 
being  partially  confounded  with  the  other,  but  arising  a  little  more  ante- 
riorly upon  the  sides  of  the  sacrum  and  coccyx;  thence,  it  passes  forwards 
and  outwards  to  be  inserted  into  the  spine  of  the  ischium. 

The  sacro-sciatic  ligaments  convert  the  two  sciatic  notches  into  foramina. 
They  not  only  serve  to  unite  the  sacrum  to  the  ilium,  but  also  contribute  tc 
the  formation  of  the  parietes  of  the  pelvis. 

3.  The  posterior  sacro-ilkic  ligament  is  a  collection  of  yellow,  elastic, 
fibrous   bundles,  intermixed   with   fatty  pellets,  which  fill  up   the   rough 


12 


FEMALE  ORGANS  OF  GENERATION. 


Pelvis  with  its  ligaments;  the  anterior  portion  remold. 
A.  Internal  iliac  fossa.  B.  Section  of  the  bones.  C.  Origin  of 
the  great  sacro-sciatic  ligament.  D.  Great  sacro-sciatic  ligament. 
E.  Lesser  sacro-sciatic  ligament.  F.  Great  sacro-sciatic  foramen. 
G.  Last  lumbar  vertebra.  II.  Ilio-lumbar  ligament.  I.  Sacro- 
veitebral  ligament. 

Fig.  10. 


Pelvis  with  its  ligaments.  Posterior  view. 
A.  Great  sacro  sciatic  foramen,  through  which  is  seen  the 
horizontal  branch  of  the  pubis.  B.  Great  sacro-sciatic  ligament. 
C.  Tuberosity  of  the  ischium.  D.  Posterior  6acro-iliac  ligament. 
E.  Posterior  superior  spinous  process  of  the  ilium.  F.  Inferior 
»acro-iliac  ligament. 


excavation  observed  behind 
the  cartilaginous  surfaces; 
very  short,  numerous,  and 
interlacing  in  every  direc- 
tion, they  become  almost  in- 
timately blended  with  lit* 
sacrum  and  coxal  bones. 
On  account  of  their  strength, 
they  greatly  consolidate  this 
articulation. 

4.  The  anterior  sacro-Mat 
ligament  is  a  simple  fibrous 
lamina,  extended  transverse- 
ly from  the  sacrum  to  the  os 
innominatum.  It  is  rather 
an  expansion  of  the  perios- 
teum of  the  pelvis  than  a 
true  ligameut. 

5.  The  superior  sacro-iliac 
ligament  is  a  very  thick  fas- 
ciculus, passing  transversely 
from  the  base  of  the  sacrum 
to  the  coxal  bone. 

6.  The  inferior  sacro-iliac 
ligament  (vertical  sacro-iliac 
of  M.  Cruveilhier)  arises 
from  the  posterior  superior 
spinous  process  of  the  ilium, 
and  is  inserted  just  below  the 
third  sacral  foramen  into  the 
tubercle  found  at  the  termi- 
nation of  the  border  of  the 
sacrum;  and  behind,  into 
the  great  sacro-sciatic  liga- 
ment. 


§  3.  Sacro-coccygeal  Articulation. 

This  articulation,  which  for  a  long  time  was  supposed  to  resemble  those 
between  the  bodies  of  the  vertebrae,  differs  from  them  materially  in  being  a 
true  arthrodia.  It  is  formed  by  the  opposition  of  the  oval  surface  of  the 
point  of  the  sacrum  to  that  of  the  base  of  the  coccyx;  the  middle  of  the 
former  is  projecting,  and  corresponds  to  a  depression  in  the  centre  of  the 
latter.  The  long  diameter  of  the  articular  face  of  the  coccyx  is  directed 
transversely.  The  cartilages  covering  these  surfaces  aie  rather  thinner  at 
the  centre  than  at  the  circumference.  They  are  provided  in  the  adult 
female  with  a  synovial  membrane,  which  is  supposed  by  M.  Lenoir  to  be 
only  developed  by  the  movements  of  the  coccyx  upon  the  sacrum,  since 
he  has  failed  to  meet  with  it  in  subjects  under  eighteen  years  of  age. 


OF     THE     PELVIS.  43 

1.  The  anterior  sacro-coccygeal  ligament  consists  of  a  few  parallel  fibres, 
which  descend  from  the  anterior  part  of  the  sacrum  to  the  corresponding 
face  of  the  coccyx. 

2.  The  posterior  sacro-coccygeal  ligament  is  flat,  triangular,  broader 
above  than  below,  and  of  a  dark  color.  Arising  from  the  margin  of  the 
inferior  orifice  of  the  sacral  canal,  it  descends  to,  and  is  lost  upon,  the 
whole  posterior  surface  of  the  coccyx.  It  also  aids  in  completing  the  canal 
behind. 

In  investigating  upon  the  dead  body  the  anatomical  arrangement  to 
which  the  motion  of  the  coccyx  on  the  sacrum  is  due,  it  was  ascertained  by 
M.  Lenoir  that  the  motion  takes  place  almost  as  frequently  in  the  sacro- 
coccygeal articulation,  as  in  that  of  the  second  piece  of  the  coccyx  witli 
the  third.  Sometimes  it  happens  simultaneously  in  both,  whilst  in  few 
cases  only  does  it  occur  in  the  connection  of  the  second  piece  with  the 
third,  or  of  the  third  with  the  fourth. 

These  inter-coccygeal  articulations  are  similarly  constructed.  In  all 
cases,  in  fact,  in  which  the  points  of  motion  of  the  coccyx  were  changed, 
M.  Lenoir  discovered  a  more  or  less  complete  anchylosis  of  the  articulation 
between  the  sacrum  and  coccyx,  and  of  those  between  the  bones  of  the 
coccyx  itself,  at  points  above  and  below  the  one  which  preserved  its 
mobility.  Then,  also,  wherever  situated,  the  movable  articulation  was 
constructed  as  follows:  1.  Of  articular  surfaces  irregular  in  form  but 
corresponding  exactly,  which  were  incrusted  with  diarthrodial  cartilages 
and  provided  with  a  synovial  membrane.  2.  Of  lax  peripheral  ligaments 
formed  at  the  expense  of  the  layers  of  fibrous  substance  covering  the  bones 
of  the  coccyx.     3.  Lastly,  motion  was  possible  in  every  direction. 

It  is  to  be  observed  that  ossification  is  more  frequent  and  rapid  in  the 
joint  between  the  sacrum  and  coccyx  than  in  that  between  the  first  piece 
of  the  coccyx  and  the  second;  the  third  and  fourth  become  fused  very 
early.  It  is  therefore  easy  to  understand  how  the  great  mobility  of  the 
sacro-coccygeal  articulations  renders  luxation  possible  in  labor,  whilst  in 
cases  of  anchylosis,  either  fracture  or  a  sudden  separation  of  the  united 
bones  might  occur. 

During  pregnancy,  the  ligaments  of  the  pelvic  articulations  become  so 
softened  and  swelled  by  imbibition  of  fluid,  as  to  render  the  mobility  of  the 
articular  surfaces  very  evident.  This  softening  is  very  considerable  in 
some  cases,  and  may  make  walking,  or  even  standing,  impossible.  (See 
Diseases  of  Pregnancy.) 

§  4.  Sacro-vertebral  Symphysis. 

This  is  produced  by  the  junction  of  the  sacrum  with  the  fifth  lumbar 
vertebra.  It  is  a  true  aniphiarthrosis,  as  are  all  the  vertebral  articulations. 
It  takes  place  at  three  different  points,  viz.,  between  the  oval  facet,  seen  at 
the  middle  of  the  base  of  the  sacrum,  and  the  inferior  surface  of  the  body 
of  the  last  vertebra;  and  at  the  two  articular  surfaces  found  near  the 
entrance  of  the  sacral  canal. 

The  modes  of  connection  are,  a  fibro-cartilage  (which  is  much  thicker  in 


44  FEMALE  ORGANS  OF  GENERATION. 

front  than  behind),  the  termination  of  the  two  anterior  and  posterior  verte- 
bral ligaments,  the  interspinous  ligament,  and  lastly,  the  sacro-vertebrai 
ligament,  a  short,  very  strong,  fibrous  bundle,  which  descends  obliquely 
from  the  anterior  inferior  part  of  the  transverse  process  of  the  last  vertebra, 
downwards  and  outwards,  towards  the  base  of  the  sacrum,  where  it  is 
inserted. 

Further,  a  synovia.1  membrane  is  found  in  the  articulation  between  the; 
oblique  process  of  the  sacrum  and  those  of  the  vertebrae. 

To  these  must  also  bo  added  the  ilio-lumbar  ligament,  which  passes  from 
the  apex  of  the  transverse  process  of  the  fifth  lumbar  vertebra  to  the 
thickest  portion  of  the  iliac  crest;  and  the  ilio-vertebral  ligament  formed 
of  two  fibrous  bands,  the  superior  of  which  arises  from  the  middle  and 
lateral  part  of  the  body  of  the  last  lumbar  vertebra,  and  the  inferior,  from 
the  inter-sacro-vertebral  space;  both  are  then  spread  out  on  the  coxal  bone. 

§  5.  Obturator  Membrane. 

The  obturator  membrane  still  claims  a  description,  in  order  to  finish  the 
history  of  the  ligamentous  apparatus  of  the  pelvis.  This,  as  has  beeD 
remarked  by  M.  Cruveilhier,  like  the  sacro-sciatic  ligaments  already 
spoken  of,  is  rather  an  aponeurosis  serving  to  complete  the  pelvic  walls, 
than  a  true  ligament. 

These  resisting  membranes  are  probably  intended  to  diminish,  in  the 
hour  of  labor,  the  compression  of  the  mother's  soft  parts,  included  between 
the  infant's  head  and  the  osseous  parietes  of  the  pelvis,  as  also  to  favor,  by 
their  elasticity,  the  passage  of  the  head  through  the  pelvic  excavation. 

Obturator  membrane. — This  membrane  subtends  the  foramen  thyroideum, 
excepting  at  its  superior  part,  where  an  opening  exists,  which  converts  the 
groove,  intended  for  the  passage  of  the  obturator  vessels  and  nerves,  into  a 
complete  canal.  Being  inserted  by  its  external  semi-circumference  into  the 
corresponding  part  of  the  periphery  of  the  obturator  foramen,  it  is  attached 
by  its  internal  half  to  the  posterior  face  of  the  ascending  ramus  of  the 
ischium.  Its  surfaces  afford  origins  for  the  two  obturator  muscles.  This 
membrane  is  composed  of  aponeurotic  fasciculi,  which  cross  each  other  in 
every  direction.     (Cruveilhier.) 

ARTICLE    III. 

OF   THE    PELVIS   IN    GENERAL. 

Studied  in  its  general  aspect,  the  pelvis  represents  a  cone,  slightly  flat- 
tened from  before  backwards;  the  base  of  which,  being  above,  is  at  the 
same  time  inclined  forwards,  whilst  the  apex  is  directed  downwards  and  a 
little  backwards. 

§  1.  External  Surface  of  the  Pelvis. 

Anatomists  have  divided  this  surface  into  four  regions:  the  anterior  of 
which  exhibits,  ^n  the  median  line,  the  front  part  of  the  symphysis  pubis. 


OF    THE     PELVIS.  45 

which  is  directed  from  above  downwards  and  from  befcte  backwards,  at  aD 
angle  with  the  perpendicular  of  some  15°  to  20° ;  next  (passing  outwards) 
is  a  smooth  surface,  from  which  several  muscles  of  the  thigh  arise,  then  the 
external  obturator  fossa,  occupied  in  the  recent  subject  by  the  muscle  of  the 
same  name,  and  finally  by  the  anterior  half  of  the  edge  of  the  cotyloid  cavity. 

The  posterior,  bounded  by  the  hinder  part  of  the  iliac  crest,  presents,  on 
(he  median  line,  the  ridge  of  the  sacral  spinous  processes,  the  inferior  open- 
ing of  the  vertebral  canal,  the  union  of  the  sacrum  with  the  coccyx,  and 
the  posterior  face  of  this  latter  bone. 

The  ten  posterior  sacral  foramina,  transmitting  the  nerves  of  the  same 
name,  are  found  in  two  deep  gutters,  on  the  sides.  These  grooves  prolong 
the  spinal  gutters,  and  are  occupied  in  the  recent  state  by  the  commence- 
ment of  the  sacro-spinal  muscles.  The  lateral  regions  may  each  be  divided 
into  two  parts:  one,  the  superior,  is  the  external  iliac  fossa;  the  other,  or 
inferior,  offers,  behind,  the  posterior  aspect  of  the  sacro-sciatic  ligaments, 
and  the  plane  of  the  notches  or  foramina  bearing  the  same  name;  and,  in 
front,  the  cotyloid  cavity  and  the  external  face  of  the  tuberosity  of  the 
ischium. 

§  2.  Internal  Surface. 

The  internal  surface  or  cavity  of  the  pelvis  has  been  aptly  compared  to 
the  basin  of  the  ancient  barbers.  (Vesalius.)  In  fact,  like  those  vessels, 
it  has  a  superior  part  which  spreads  out  freely,  and  is  called  the  great,  the 
superior,  or  the  abdominal  pelvis;  and  an  inferior  one,  more  contracted, 
bearing  the  title  of  the  little  pelvis,  or  pelvic  excavation. 

1.  The  great  pelvis  has  a  very  irregular  figure,  and  forms  a  species  of 
pavilion  to  the  entrance  of  the  pelvis.  Its  walls  are  three  in  number:  the 
anterior  one  is  deficient  in  the  dried  skeleton,  but  in  the  living  state  it  is 
supplied  by  the  anterior  abdominal  muscles;  its  posterior  parietes  exhibit 
a  notch  in  its  middle,  that  is  ordinarily  filled  up  by  the  projection  of  the 
last  lumbar  vertebrae,  which  are  usually  left  in  connection  with  the  pelvis, 
although  in  reality  not  forming  any  part  of  it.  Two  gutters  are  found  on 
the  sides  of  this  eminence,  occupied  by  the  psoae  muscles;  further  outwards, 
the  anterior  part  of  the  sacro-iliac  symphyses  appear,  which  constitute  the 
boundaries  between  the  posterior  and  lateral  regions:  these  hitter  are  con- 
stituted by  the  internal  iliac  fossa?,  covered  by  the  iliacus  interims  muscles. 

2.  The  lesser  pelvis,  or  basin.  This  forms  a  curved  canal,  larger  in  the 
middle  than  at  its  extremities,  and  slightly  bent  forward.  If  all  the  parts 
described  as  appertaining  to  the  great  pelvis  be  removed  by  the  saw,  as 
recommended  by  Chaussier,  a  species  of  ring  will  remain,  whose  circum- 
ference, being  narrow  in  front  and  much  broader  behind,  will  furnish  a 
correct  idea  of  the  shape  of  the  pelvis.  Four  regions  are  found  in  this 
cavity  also: 

The  anterior  one  is  concave  transversely,  and  is  inclined  upwards,  having 
the  posterior  part  of  the  pubic  articulation  near  its  middle:  this  is  generally 
prominent,  assuming  the  form  of  a  longitudinal  pad,  which  may  in  some 
cases  project  to  the  extent  of  from  two  to  three-eighths  of  an  inch.    Towards 


46  FEMA.LE     ORGANS     OF     GENERATION. 

the  sides  a  smooth  surface  appears,  and  then  the  internal  obturator,  or  sub- 
pubic fossa,  having,  at  its  upper  external  part,  the  inner  orifice  of  the  sub- 
pubic canal,  through  which  the  external  obturator  vessels  and  nerves  pass 
out  from  the  pelvis. 

It  is  not  at  all  uncommon  for  females  to  complain  during  labor  of  severe 
cramps  in  the  muscles  of  the  upper  internal  part  of  one  thigh.  These  pains 
result  from  the  pressure  made  by  the  child's  head  upon  those  nerves,  as  it 
glides  over  this  portion  of  the  excavation. 

The  posterior  region  —  constituted  by  the  front  face  of  the  sacrum  and 
coccyx  —  is  directed  downwards,  and  is  concave  from  above,  downwards. 
It  consequently  exhibits  those  peculiarities  already  noticed  when  describing 
the  sacrum. 

The  lateral  regions  present  two  quite  distinct  portions:  the  anterior  one 
is  wholly  osseous,  corresponding  to  the  back  part  of  the  cotyloid  cavity,  and 
to  the  body  and  tuberosity  of  the  ischium.  It  is  directed  from  above  down- 
wards, from  behind  forwards,  and  from  without  inwards. 

The  posterior  one  is  formed  by  the  internal  face  of  the  greater  and  lesser 
sacro-sciatic  ligaments,  and  by  the  internal  aspect  of  the  great  and  small 
sciatic  notches,  converted  by  them  into  foramina;  it  has  an  opposite  direc- 
tion to  the  former.  One  of  these  foramina  is  larger  and  situated  higher  up 
than  the  other,  and  is  of  an  oval  form.  The  other  is  triangular,  smaller, 
and  more  inferior.  The  pyramidal  muscle,  the  great  sciatic  nerve,  gluteal 
artery,  and  the  internal  pudic  vessels  and  nerves,  escape  from  the  pelvis 
through  the  great  sciatic  foramen.  The  small  sciatic  hole  is  filled  up  by 
the  obturator  internus  muscle,  and  the  internal  pudic  vessels  and  nerves, 
which  re-enter  the  pelvis  in  order  to  supply  the  perineum. 

If  two  vertical  sections  be  made,  the  one  extending  on  the  median  line 
through  the  sacrum  and  the  pubis,  dividing  the  pelvis  into  two  lateral 
halves,  and  the  other  at  right  angles  to  the  first,  dividing  it  into  anterior 
and  posterior  halves,  four  equal  parts  or  quarters  of  the  pelvis  will  be 
thereby  produced,  which  accoucheurs  have  designated  as  the  anterior  and 
"posterior  inclined  planes.  Desormeaux  included  only  the  lateral  regions  of 
the  excavation,  which  he  divided  into  two  equal  parts,  in  the  composition 
of  these  planes:  according  to  him,  the  anterior  inclined  planes  are  con- 
tinuous with  the  anterior  region ;  the  posterior,  with  the  front  face  of  the 
sacrum;  and  the  spine  of  the  ischium  is  found  at  the  point  of  union  of  these 
two.  The  direction  of  the  inclined  planes  is  always  the  same,  wdiatever  be 
the  manner  in  which  they  are  formed.  That  is,  the  anterior  are  directed 
from  without  inwards,  from  above  downwards,  and  from  behind  forwards; 
the  posterior,  from  without  inwards,  from  above  downwards,  and  from 
before  backwards  —  in  a  word,  in  such  a  way  as  to  resemble  somewhat  the 
four  sides  of  a  lozenge  which  is  slightly  curved  in  its  length.  By  most 
authors,  these  inclined  planes  are  supposed  to  play  an  important  part  in  the 
mechanism  of  labor:  for  they  imagine  that  their  direction  has  an  immediate 
influence  upon  the  movements  which  the  head  of  the  foetus  performs  in  the 
excavation. 

In  anticipating  that  the  description  of  the  mechanism  of  labor  hereafter 


OF     THE     PELVIS.  47 

given  will  invalidate  this  assertion,  we  shall  simply  observe  that  the  move- 
ments of  rotation  executed  by  the  head,  take  place  more  frequently  whilst 
the  latter  is  strongly  bulging  out  the  perineum,  and  is  so  far  below  the 
inclined  planes  as  scarcely  to  feel  the  influence  of  their  direction,  and  further, 
that  these  motions  often  occur  in  an  opposite  direction. 

The  great  and  the  lesser  pelvis  are  separated  from  each  other  by  a  kind 
of  horizontal  circle,  which  has  been  designated  by  accoucheurs  as  the  abdom- 
inal, or  superior  strait,  the  isthmus,  or  margin  of  the  pelvis.  Finally,  the 
apex  of  the  pelvis  presents  an  opening  that  is  limited  by  a  circle,  partly 
osseous,  partly  ligamentous,  to  which  the  name  of  the  inferior  strait  has 
been  applied.  Consequently,  these  two  straits  are  the  extreme  limits  of  the 
pelvic  excavation. 

§  3.  Of  the  Superior  Strait. 

The  superior  strait  is  formed,  behind,  by  the  sacro-vertebral  angle,  and 
the  anterior  border  of  the  wings  of  the  sacrum :  outwardly,  by  the  rounded 
margin  that  bounds  the  internal  iliac  fossa  below;  and  in  front,  by  the  ilio- 
pectineal  eminence  and  the  horizontal  ramus  of  the  pubis,  terminating  at 
the  symphysis  of  this  bone.  The  abdominal  strait  has  been  variously  com- 
pared to  an  ellipse,  an  oval,  and  to  the  heart  of  a  playing-card.  We  may 
assert,  however,  with  Chaussier,  that  its  shape  is  that  of  a  curvilinear 
triangle,  the  angles  of  which  have  been  rounded  off,  and  having  its  base 
behind  and  the  apex  in  front. 

It  constitutes  the  entrance  to  the  lesser  pelvis,  and  is  therefore  the  first 
part  of  the  narrow  canal  which  the  fcetus  has  to  traverse.  Hence,  the  pains 
taken  by  accoucheurs  to  study  this  osseous  opening  can  readily  be  conceived. 

All  the  modern  authors  since  the  days  of  Deventer,  have  endeavored  to 
fix  precisely  the  degree  of  inclination  of  its  plane  and  axis,  to  ascertain  the 
direction  the  foetus  should  follow  in  engaging  in  the  pelvic  canal,  and  to 
determine  carefully  the  dimensions  of  the  latter,  and  their  accordance  with 
those  of  the  body,  which  is  to  pass  through  it. 

The  plane  of  the  superior  strait  is  inclined  obliquely  from  above  dosvn- 
wards,  and  from  behind  forwards;  but  writers  are  far  from  being  unanimous 
in  regard  to  the  degree  of  its  inclination ;  that  is,  in  determining  the  angle 
formed  by  the  sacro-pubic  line,  at  the  point  where  it  meets  a  horizontal  one, 
drawn  from  the  superior  part  of  the  symphysis  pubis  towards  one  of  the 
points  on  the  anterior  face  of  the  sacrum.  Although  originally  placed  at 
45°  by  J.  J.  Miiller  (1745),  this  angle  has  successively  been  fixed  at  35° 
by  Levret;  at  75°  by  Camper,  and  at  55°  by  Saxtorph ;  and  still  more 
recently,  Professor  Nsegele,  after  a  great  number  of  researches,  has  con- 
cluded to  consider  it  as  an  angle  of  60°  (1819).  It  is  now  generally  ad- 
mitted that  the  degree  of  inclination  in  the  plane  of  the  superior  strait  is 
from  55°  to  60°  in  the  erect  position  of  the  female. 

The  direction  of  the  plane  being  once  understood,  it  is  an  easy  matter  to 
ascertain  that  of  its  axis;  for  the  latter  being  a  line  which  falls  perpen- 
dicularly upon  the  centre  of  this  plane,  it  must  evidently  form  with  the 
vertical  the  same  angle  that  the  plane  itself  does  with  the  horizontal  line, 


48 


FEMALE    ORGANS    OF    GENERATION. 


and  consequently  must  have  just  the  same  degree  of  inclination.  Being 
thus  uuderstood,  the  axis  of  the  superior  strait  is  a  line  (a  b,  Fig.  12)  which, 
commencing  near  the  umbilicus  of  the  female,  would  pass  directly  through 
the  centre  of  this  strait,  and  fall  upon  the  point  of  union  of  the  upper  two- 
thirds  of  the  coccyx,  with  its  inferior  third.  Hence,  it  will  be  directed 
from  above  downwards,  and  from  before  backwards.  Further,  the  inclina- 
tion of  this  plane  varies  according  to 
Fl°- ll-  the  woman's  position.     Thus,  it  is  al- 

most nothing  when  recumbent,  and 
sometimes  in  this  position  the  plane 
of  the  superior  strait  instead  of  being 
directed  forwards  and  upwards,  even 
looks  upwards  and  backwards  (Du- 
bois) ;  when  the  trunk  is  bent  strongly 
forwards,  the  inclination  of  the  plane 
is  diminished  and  becomes  more  nearly 
horizontal ;  towards  the  end  of  gesta- 
tion, on  the  contrary,  the  inclination 
increases,  especially  when,  in  order  to 
restore  equilibrium,  the  upper  part  of 
the  body  is  carried  much  backwards. 

As  the  figure  which  represents  the 
circumference  of  the  superior  strait  is 
not  a  perfect  circle,  its  dimensions, 
taken  at  different  points,  are,  of  course, 
unequal,  and,  accordingly,  writers  have 
admitted  several  diameters  for  it,  thus : 

There  are  three  principal  ones  (Fig.  2),  namely,  an  antero-posterior  or 
sacro-pubic  diameter  a  a,  which  extends  from  the  sacro-vertebral  angle  to 
the  upper  part  of  the  symphysis  pubis;  it  is  from  four  and  a  quarter  to 
four  and  a  half  inches  in  length.     2.  A  transverse  one,  b  b,  passing  from 

the  middle  of  the  rounded  border 
Fl°-  12-  that  terminates  the  iliac  fossa  of 

one  side,  to  the  same  point  on 
the  opposite  side;  this  is  five 
and  a  quarter  inches  long. 
3.  An  oblique  diameter,  c  c,  ex- 
tending from  the  anterior  part 
of  the  sacro-iliac  symphysis  to 
the  ilio-pectineal  eminence  of  the 
opposite  side;  this  is  found  on 
both  sides,  and  is  four  and 
three-quarters  inches  long. 

Lastly,  M.  Velpeau  admits  a 
fourth  diameter,  called  by  him 
the    sacro-cotyloidean ;     before 

rt  a.  The  antero-posterior,  or  mcro-publc  diameter.    6  6.       described,     however,     by    Bums, 
The  transverse  diameter,     c  c.  The  two  oblique  diameters.  *  „ 

« <•..  The  sacro-cotyioid  intorvai.  under  the  more  exact  name  of 


c  /(.  The  plane  of  the  superior  strait  prolonged 
beyond  the  pubis,  c  e.  The  plane  of  the  inferior 
■trait  prolonged  beyond  the  pubis,  c  d.  Shows  the 
departure  of  this  plane  from  the  horizontal  line. 
a  b.  The  axis  of  the  superior  strait,  g  f.  The  axis 
of  the  inferior  strait. 


OF    THE    PELVIS.  49 

the  sacro-cotyloid  interval  a  c,  existing  between  the  promontory  and  the 
posterior  part  of  the  cotyloid  cavity.  This  interval,  according  to  the 
examinations  of  the  French  surgeon,  is  from  four  to  four  and  one-eighth 
inches  in  extent;  but  from  the  results  of  Nregele  and  Stoltz's  researches  it 
is  much  less,  being  scarcely  three  and  a  half  inches  (the  mean  obtained 
from  ninety  pelves).  The  circumference  of  this  strait  varies  from  thirteen 
to  seventeen  inches ;  Levret  taught,  that  it  equalled  one-fourth  of  the  female's 
height;  but  to  establish  such  an  approximation,  the  development  of  the 
pelvis  should  always  be  in  direct  proportion  to  the  stature  of  the  individual, 
which  is  certainly  not  the  fact. 

§  4.  Of  the  Inferior  Strait. 

The  inferior  strait  —  the  perineal  strait  —  or  apex  of  the  pelvis  (as  it  is 
variously  called),  is  more  irregular  in  shape  than  the  superior  one.  Its 
outline  presents,  in  fact,  three  tuberosities  or  osseous  projections,  separated 
by  as  many  deep  notches. 

If,  however,  the  advice  of  Chaussier  be  followed,  and  a  sheet  of  paper  be 
placed  over  this  opening,  so  as  to  trace  its  outline  with  a  crayon,  it  will  be 
found  to  have  an  oval  figure,  the  smaller  extremity  of  which  is  in  front.. 
and  the  larger  one,  looking  backwards,  is  broken  in  upon  by  the  prominence 
of  the  coccyx.  This  point,  disappearing  at  the  moment  of  the  head's  pas- 
sage, offers  no  obstacle  to  the  delivery;  and,  therefore,  the  strait  may  be 
considered  as  nearly  an  oval. 

The  periphery  of  the  pelvis  at  its  apex  is  formed  by  the  inferior  part  of 
the  symphysis  pubis,  the  descending  branch  of  this  bone,  the  ascending 
branch  and  tuberosity  of  the  ischium,  the  inferior  margin  of  the  great  sacro- 
sciatic  ligament,  and  by  the  border  and  point  of  the  coccyx.  Hence,  three 
triangular  projections  are  found  in  it :  the  two  ischia  upon  the  sides,  and 
the  coccyx  behind.  The  first  two  are  immovable,  but  the  last,  on  the  con- 
trary, is  effaced  at  the  period  of  delivery,  as  just  mentioned ;  for  the 
mobility  of  the  sacro-coccygeal  articulation  allows  the  coccyx  to  be  pushed 
downwards  and  backwards  by  the  fcetal  head,  as  it  traverses  the  inferior 
strait.  The  two  lateral  prominences,  made  by  the  tuberosities  of  the  ischia, 
are  placed  on  a  plane  somewhat  lower  than  the  point  of  the  coccyx  ;  and 
consequently,  in  the  sitting  posture,  the  weight  of  the  body  rests  solely  on 
those  tuberosities,  and  not  at  all  upon  the  coccygeal  extremity.  This  cir- 
cumstance furnishes  us  a  reason  why  transverse  contractions  of  the  pelvis 
are  far  more  frequent  at  the  inferior  strait  than  the  antero-posterior  ones. 

The  three  notches  also  require  a  passing  notice;  thus,  the  two  postero- 
lateral ones  are  very  deep,  but  when  the  sciatic  ligaments  have  been  pre- 
Bcrved,  they  are  comparatively  superficial ;  the  third  is  found  anteriorly; 
its  apex  corresponds  to  the  inferior  part  of  the  symphysis  pubis,  its  base  to 
a  line  drawn  between  the  anterior  parts  of  the  tuberosities  of  the  ischia, 
and  its  sides  are  formed  by  the  ischio-pubal  rami.  The  term  arch  of  the 
pubis  has  been  applied  to  this  notch.  The  columns  of  the  arch  arc  distorted 
outwardly,  as  if  a  rounded  body  had  been  forcibly  expelled  from  the  pelvis, 
whilst  the  bones  were  soft,  and  had  pushed  them  before  ii  ;  and  this  arrange1 
4 


50 


FEMALE  ORGANS  OF  GENERATION. 


ment,  which  is  more  marked  in  the  female  than  the  male,  favors  the  descent 
of  the  head.  The  arch  is  three  and  a  half  to  three  and  three-quarter  inches 
hroad  at  the  base ;  but  only  one  and  a  quarter  to  one  and  a  half  inches  at 
its  apex  ;  in  height,  it  is  about  two,  to  two  and  a  half  inches.  Hence  the 
area  of  the  inferior  strait  will  not  present  a  uniform  plane  (should  it  be 
desirable  to  ascertain  the  irregularities  it  exhibits),  because  all  parts  of  its 
margin  are  not  upon  the  same  level.  However,  to  obviate  the  difficulty 
met  with,  in  determining  the  direction  of  this  plane,  Duges  has  divided  the 
3trait  into  two  nearly  equal  portions,  the  one  anterior,  and  the  other  pos- 
terior, meeting  at  the  tuberosities  of  the  ischium,  and  each  presenting  a 
distinct  plane  and  axis;  but  as  this  method  of  proceeding  uselessly  com- 
plicates the  question,  we  prefer  considering  the  terminal  plane  of  the  pelvis, 
as  represented  by  the  coccy-pubal  line,  thus  leaving  out  the  lateral  projec- 
tions altogether. 

The  question  is  then  reduced  to  these  terms:  What  is  the  direction  of  the 
line  that  extends  from  the  point  of  the  coccyx  to  the  inferior  part  of  the 
symphysis  pubis? 

Writers,  likewise,  variously  describe  this;  for  instance,  according  to  the 
majority  of  the  French  accoucheurs,  the  plane  of  the  inferior  strait  is  slightly 
oblique,  from  below  upwards,  and  from  behind  forwards,  so  that  it  would 
unite  with  that  of  the  superior  strait  (if  prolonged)  in  front  of  the  symphysis 
pubis.  On  the  other  hand,  M.  Nregele  concludes,  from  his  numerous 
res<  arches,  that  the  inclination  of  the  antero-posterior  diameter  of  this  strait 
is  from  10°  to  11°  from  the  horizon,  and  that  the  point  of  the  coccyx  is 
found,  as  a  mean,  from  a  half  to  three-quarters  of  an  inch  higher  than  the 
Bummit  of  the  pubic  arch ;  and,  therefore,  the  coccy-pubal  line  is  a  little 
oblique  from  above  downwards,  and  from  behind  forwards.  The  lower 
extremity  of  the  axis  of  this  plane  of  the  inferior  strait  would  cut  the  coccy- 
pubic  diameter  at  right  angles,  and  terminate  above  at  the  sacro-vertebral 
angle.     As  a  further  result  of  his  labors,  he  has  found  that,  in  five  hundred 

well-formed  persons,  of  different  stat- 
FlG- ia  ures,  four  hundred  and  fifty-four  have 

the  point  of  the  coccyx  more  elevated 
than  the  inferior  portion  of  the  sym- 
physis; in  twenty-six  it  was  lower, 
and  in  twenty  individuals  both  points 
were  on  the  same  level.  M.  Velpeau 
remarks,  as  we  think  with  some  reason, 
that,  at  the  moment  of  delivery,  —  the 
only  time,  after  all,  when  it  is  requisite 
to  form  an  idea  of  the  direction  of 
this  plane,  —  the  point  of  the  coccyx, 
being  pushed  downwards  and  back- 

I     (/     £     wards  by  the  passage  of  the  head,  is  at 

least  on  a  level  with,  if  not  lower  than 
c  d.  The  horizontal  line,  c  e.  The  piano  of  the  in-     tjie  inferior  part  of  the  svmphysis. 

ferior  strait  (during  lal>r).    a  b.  The  axis  of  the  in-  .  _    _.r       \     J 

terior  strait  I  he  assertion  of  M.  JNajgele,  there- 


OF    THE    PELVIS. 


51 


Fio.  14. 


fore,  although  true  as  applied  to  the  female  not  in  labor,  fails  during 
parturition ;  and  it  must  be  admitted  that  th«j  plane  of  the  inferior  strait  is 
then  oblique  from  below  upwards,  and  from  behind  forwards. 

The  axis  of  this  strait  is  represented  by  a  line  (a  b,  Fig.  13)  directed  from 
above  downwards,  and  from  behind  forwards,  which,  starting  from  the  first 
piece  of  the  sacrum,  falls  at  a  right  angle  upon  the  middle  of  the  bis- 
ischiatic  space.  The  remarks  made  upon  the  variations  in  the  direction 
of  the  plane,  apply  with  equal  force  to  its  axis.  The  latter  crosses  the  axis 
of  the  superior  strait  in  the  excavation,  forming  with  it  an  obtuse  angle, 
the  sine  of  which  is  in  front. 

It  is  also  very  important  to  know  the  dimensions  of  the  perineal  strait, 
and  hence  obstetricians  describe  three  principal  diameters  at  that  point, 
namely  —  1.  The  antero-posterior  or 
coccy-pubal  diameter  (a  a,  Fig.  14), 
running  from  the  point  of  the  coccyx 
to  the  summit  of  the  pubic  arch  ;  it 
is  usually  four  and  a  quarter  inches 
long,  but  may  increase  to  four  and 
three-quarter  inches  during  labor,  by 
the  retrocession  of  the  coccyx.  2.  The 
bis-ischiatic,  or  transverse  diameter, 
b  b,  is  four  and  a  quarter  inches  in 
ength,  and  goes  from  one  tuberosity 
J  the  ischium  to  the  other.  3.  The 
oblique  diameter,  c  c,  commences  at 
the  middle  of  the  great  sacro-sciatic 
ligament,  and  crosses  to  the  point  of 
union  of  the  ascending  branch  of  the 
ischium,  with  the  descending  ramus 

of  the  pubis,  and  is  four  and  a  quarter  inches  long,  but  may  become  one- 
quarter  of  an  inch  more  during  labor,  from  the  elasticity  of  these  ligaments. 

All  the  diameters  of  the  inferior  strait  are,  therefore,  in  the  dried  pelvis, 
about  four  and  a  quarter  inches  in  length,  though  their  dimensions  are 
susceptible  of  great  variation  during  labor. 

§  5.  Of  the  Excavation. 

The  excavation  is  that  space  comprised  between  the  superior  and  the 
inferior  straits,  and  it  is  in  this  cavity  that  the  fcetal  head  executes  its  prin- 
cipal movements;  and  it  is  somewhat  surprising,  that,  until  quite  recently, 
this  canal  was  scarcely  mentioned  in  the  majority  of  the  classic  works,  not- 
withstanding the  importance  of  a  knowledge  of  its  dimensions,  as  also  of 
the  direction  of  its  plane  and  axis. 

Its  dimensions  comprise  both  the  height  and  width  at  the  different  points: 
thus  the  height  in  front,  is  one  and  a  half  inches ;  upon  the  sides,  three  and 
three-quarter  inches ;  whilst  it  is  four  and  a  quarter  inches  behind,  if  a 
Btraight  line  be  drawn  from  the  sacro-vertebral  angle  to  the  point  of  the 
coccyx,  and  five  inches  and  a  quarter,  following  the  curve  of  the  sacrum. 


a  a.  The  anteroposterior  or  coccy-pubal  diameter. 
b  b.  The  transverse  or  bis-ischiatic  diameter,  c  c.  Th« 
two  oblique  diameters. 


52 


FEMALE  ORGANS  OF  GENERATION". 


Three  diameters  are  also  described  for  this  cavity  (like  the  straits),  so  aa 
to  appreciate  its  extent  in  the  different  directions.  All  of  them  are  taken 
at  the  centre  of  the  excavation,  and  they  consist  of  an  antero-posterior  one, 
of  four  and  three-quarters  to  five  and  one-eighth  inches  in  length,  a  trans- 
verse diameter  four  and  three-quarter  inches  long,  and  an  oblique  one,  of 
the  same  length ;  consequently,  all  the  diameters  of  this  cavity  are  very 
nearly  four  and  three-quarter  inches  each. 

If  the  canal  forming  the  excavation  were  a  cylinder,  it  would  only  be 
necessary  to  divide  it  by  a  plane,  perpendicular  to  its  walls,  in  order  to 
represent  the  opening  of  this  cavity ;  but  a  simple  division,  thus  made,  would 
not  give  a  just  conception  of  the  excavation,  for  two  reasons.  First,  the 
canal  is  not  cylindrical,  because  its  sides  are  not  parallel,  and  the  anterior 

face  of  the   sacrum   presents   a 
FlQ- 15-  well-marked  curvature ;  the  pubic 

wall  being  nearly  straight,  and 
the  lateral  parietes  very  oblique 
from  without  inwards,  and  from 
above  downwards.  Consequently, 
to  furnish  an  exact  idea  of  the 
general  arrangement  of  the  pelvic 
excavation,  it  seems  necessary  to 
divide  the  canal  (see  Fig.  15)  by 
a  series  of  planes,  all  passing 
from  the  point  c  (the  point  of 
intersection  of  the  planes  of  the 
superior  and  inferior  straits)  to 
any  point  whatever,  p  q  r  s  t,  on 
the  anterior  face  of  the  sacrum. 
Each  of  these  planes  will  show 
the  opening  of  the  pelvic  cavity 
at  the  level  where  it  is  found. 
Now,  to  determine,  with  cer- 
tainty, the  direction  of  the  gen- 
eral axis  of  this  excavation,  it  is 
requisite  to  raise  a  perpendicular  line  from  the  geometrical  centre  of  each 
of  these  sections,  and  to  draw  a  line  g  k  through  the  base  of  each. 

This  line  g  k  (which,  as  the  student  will  observe,  is  not  straight)  is  called 
the  general  axis  of  the  pelvis. 

It  is  now  readily  understood  that  this  line  is  nearly  parallel  to  the 
anterior  face  of  the  sacrum,  and  its  extremities  correspond  with  the  axes  of 
the  superior  and  the  inferior  straits ;  hence,  this  curve  exactly  represents 
the  whole  axis  of  the  pelvis,  or,  in  other  words,  the  line  which  the  foetus 
must  follow  in  traversing  the  pelvic  excavation. 

It  would  be  wrong  to  consider  the  line,  representing  the  entire  axis  of  the 
excavation,  as  a  simple  curve ;  for  M.  Nsegele  has  well  observed,  that  it 
cannot  be  composed  of  two  straight  lines,  as  often  taught,  nor  is  it  a  simple 
arc  of  a  circle.     In  fact,  the  anterior  face  of  the  bodies  of  the  first  two  bones 


a  b.  The  plane  of  the  superior  strait,  i  d.  The  plane  of 
the  inferior  strait,  c.  The  point  where  these  two  planes 
would  meet,  if  prolonged,  m  n.  The  horizontal  line. 
if.  The  axis  of  the  superior  strait,  g  k.  The  axis  of  the 
excavation,  p  q  r  s  t.  Various  points  taken  on  the  sacrum 
to  show  the  plane  of  the  excavation  at  each  point. 


OP    THE    PELVIS.  53 

of  the  sacrum  forms  a  straight  line ;  the  sacral  curve  embracing  only  the 
last  three  bones.  Consequently,  the  central  line,  which  is  evidently  parallel 
to  this,  will  consist  of  a  straight  and  a  curved  portion  —  straight,  for  that 
part  of  the  excavation  corresponding  to  the  two  superior  vertebrae,  and 
curved  in  the  space,  which  is  bounded  behind  by  the  last  three  sacral 
vertebra?,  and  in  front  by  the  anterior  pelvic  walls. 

§  6.  Base  of  the  Pelvis. 

The  base  of  the  cone,  represented  by  the  pelvis,  has  its  circumference 
directed  upwards  and  in  front ;  it  exhibits,  behind,  a  notch,  into  the  bottom 
of  which  the  base  of  the  sacrum  projects,  and  which  is  further  filled  up  by 
the  last  lumbar  vertebrae  (generally  left  in  situ  to  complete  the  posterior 
wall  of  the  greater  pelvis),  by  the  ilio-lumbar  ligaments,  and  by  the  qua- 
dratus  lumborum  muscles  ;  2,  outwardly,  the  anterior  two-thirds  of  the  iliac 
crest  furnishing  attachments  to  the  external  and  the  internal  oblique  and 
transversalis  abdominis  muscles ;  and  3,  in  front,  the  anterior  superior  and 
inferior  spinous  processes  of  the  ilium,  the  groove  for  the  passage  of  the  con- 
joint muscles — the  psoas  magnus  and  iliacus  internus,  the  ilio-pectineal 
eminence,  the  superior  border  of  the  horizontal  branch  of  the  pubis,  the 
spine,  and  lastly,  the  upper  margin  of  the  symphysis  of  this  bone. 

§  7.  Differences  of  the  Pelvis. 

1.  According  to  the  sex.  Considered  as  a  whole,  the  pelvis  in  the  male 
is  smaller  but  deeper,  the  bones  are  thicker,  and  the  muscular  impressions 
more  marked,  than  in  the  female.  The  superior  strait  being  more  retracted, 
resembles  the  figure  of  a  heart  on  a  playing-card.  The  excavation  is  not 
so  wide,  though  it  is  deeper,  especially  in  front,  owing  to  the  greater  length 
of  the  symphysis  pubis;  the  arch  of  the  pubis  is  straight,  nearly  triangular 
in  shape,  and  is  not  widened  in  front.  The  coccyx  is  early  joined  to  the 
sacrum,  and  the  articulations  of  the  pelvis  are  much  sooner  anchylosed 
than  in  the  female.  In  the  latter,  we  may  add,  that  the  iliac  fossae  are 
larger  and  more  warped  outwardly  (whence  the  prominence  of  the  haunch 
bones),  and  the  iliac  crest  less  twisted  in  the  form  of  an  italic/;  the  interval 
separating  the  angle  of  the  pubis  from  the  cotyloid  cavity  is  more  consider- 
able, causing,  in  part,  the  projection  of  the  great  trochanters,  and  a  wider 
separation  of  the  femurs  ;  the  superior  strait  is  larger  and  more  elliptical ; 
the  curve  of  the  sacrum  deeper  and  more  regular;  the  tuberosities  of  the 
ischium  are  farther  apart;  the  pubic  symphysis  shorter;  the  foramen  thyroi- 
deum  more  triangular;  the  arch  of  the  pubis  broader,  more  rounded,  and 
more  curved,  and  the  lateral  borders,  formed  by  the  ischio-pubic  ramus, 
more  contorted  outwardly. 

2.  According  to  the  age.  At  birth,  the  pelvis  is  extremely  narrow  and 
elongated,  and  of  such  inconsiderable  dimensions,  that  its  cavity  will  not 
contain  several  of  the  organs  afterwards  found  in  it;  from  which  circum- 
stance, the  protuberance  of  the  belly,  observed  in  the  foetus  and  in  children 
at  term,  in  great  measure  results;  the  excavation  has  the  form  of  a  cone, 
the  abdominal  strait   being  strongly  inclined  downwards;  the  sacrum  is 


54 


FEMALE  ORGANS  OF  GENERATION. 


nearly  flat,  anil  so  much  elevated  that  a  horizontal  line  diawn  front  the 
superior  part  of  the  pubis  would  pass  beneath  the  coccyx ;  the  coxal  bonea 
are  narrow,  elongated,  and  nearly  straight  at  their  superior  part,  ana  the 
cartilaginous  iliac  crests  are  not  twisted. 

From  this  disposition  it  necessarily  happens  that  the  greatest  diameter  of 
the  pelvis  extends  from  the  sacrum  to  the  pubis.  Burns  declares  that  this 
form  changes  by  degrees  as  the  little  girl  advances  in  age:  thus,  the — 


1 

Antero-posterior  diameter  measures  . 
Transverse  diameter  measures,   .    .   . 

At  9  years. 

At  10  yearn. 

At  13  years. 

At  14  years.   At  18  years./ 

2J4  inches. 
2%  inches. 

314  inches. 

3  in.  0  lines. 

&hi  inches. 

3%  inches. 

3%  inches. 

4  inches. 

3%  inches. 
i]/2  inches. 

[3.  According  to  Races.  This  subject,  studied  by  Vrolick  and  Dubois,  has  been 
recently  taken  up  by  Joulin,  who  published  an  important  memoir  on  it,  in  which 
he  proves  that  there  is  nothing  characteristic  in  the  differences  to  be  observed  in 
the  pelves  of  the  three  races,  Aryan,  Negro,  and  Mongol ;  in  the  two  latter  espe- 
cially, the  resemblance  is  so  strong  that  it  is  impossible  to  distinguish  them.  The 
same  author  states  that,  contrary  to  what  has  been  said,  in  all  human  races  the 
transverse  diameter  of  the  superior  strait  is  greater  than  the  antero-posterior ; 
but  that  the  oblique  diameter  of  the  superior  strait  of  the  pelvis  of  the  Negress  and 
Mongol  female  differs  from  the  transverse  by  a  few  millimeters  only,  whilst  in  the 
Aryan  female  the  difference  amounts  to  a  centimetre  and  a  half.  The  pelves  of  the 
Negro  and  Mongol  are,  besides,  less  capacious  than  those  of  the  white  race;  they 
have  less  depth,  and  the  pubic  arch  is  wider  by  several  degrees.] 

§  8.  Uses  of  the  Pelvis. 

The  pelvis  constitutes  the  base  of  the  trunk,  and,  according  to  Desor- 
meaux,  it  forms  a  complete  ring,  that  may  be  reduced  to  two  arches;  the 
posterior  and  superior  of  which  receives  the  whole  weight  of  the  trunk, 
whilst  the  anterior  and  inferior  one  serves  as  a  buttress  to  it. 

The  two  lower  extremities  are  attached  to  the  lateral  parts  of  this  circle, 
and  support,  in  the  erect  posture,  all  the  weight  of  the  superior  part  of  the 
body.  This  use  of  the  pelvis  satisfactorily  explains  to  the  accoucheur  the 
vicious  forms  the  cavity  often  assumes  when  ossification  is  retarded,  or  when- 
ever any  disease  alters  and  softens  the  bones. 

Another  function  of  the  pelvis  is  to  inclose  and  protect  the  bladder, 
rectum,  and  seminal  vesicles  of  the  male;  the  uterus,  Fallopian  tubes,  and 
ovaries  in  the  female.  During  gestation,  it  sustains  and  gives  a  proper 
direction  to  the  womb ;  and  in  labor,  it  affords  a  passage  to  the  child. 


ARTICLE    IV. 

OF   THE   PELVIS,   COVERED   BY   THE   SOFT   PARTS. 

It  will  not  suffice  to  study  the  pelvis  as  found  in  the  skeleton  alone,  for 
the  changes  produced  in  its  form  and  dimensi:ns  in  the  living  female,  by 
the  arrangement  of  the  soft  parts,  also  require  our  special  attention. 


OF    THE    PELVIS. 


Fio.  16. 


Being  continuous  above  with  the  abdomen,  the  great  pelvis  incloses  and 
supports  the  mass  of  the  intestines,  and  affords  points  of  attachment  bv  its 
walls  to  two  orders  of  muscles.  The  one  destined  to  form  the  inclosure  of 
the  belly  fills  the  large  opening  exhibited  in  front,  and  thus  constitutes  the 
anterior  abdominal  wall ;  the  extensibility  of  which,  in  comparison  with 
the  resistance  of  the  posterior  plane,  accounts  readily  for  the  tendency  of 
the  uterus  to  incline  forward  in 
the  advanced  stage  of  gestation. 
The  others,  two  in  number,  are 
placed  in  the  iliac  fossae ;  they 
are  the  iliacus  iuternus,  and  the 
psoas  magnus  muscles,  which, 
from  being  situated  on  the  late- 
ral parts  of  the  abdominal  strait, 
change  both  its  form  and  di- 
mensions. The  first  of  these 
has  radiated  fibres,  and  occu- 
pies the  iliac  fossae ;  the  second 
descends  from  the  sides  of  the 
lumbar  vertebrae,  and  after  hav- 
ing been  joined  to  the  preced- 
ing, is  inserted  into  the  lesser 
trochanter  of  the  thigh  bone. 
These  two  muscles,  surrounded 
and  confined  by  an  aponeurosis 
(fascia  iliaca),  may  be  regarded 
as  a  sort  of  cushion,  forming  a 
convenient  support  to  the  de- 
veloped uterus,  and  destined  to  protect  it  by  the  elasticity  of  the  soft  parts 
against  the  shocks  and  concussions  continually  produced  by  locomotion. 
Notwithstanding  the  presence  of  these  muscles,  the  strait  still  resembles  a 
curvilinear  triangle  in  shape,  the  base,  however,  of  the  triangle  being  in 
front  instead  of  behind,  as  it  was  in  the  dried  pelvis ;  the  transverse  diam- 
eter is  diminished  half  an  inch  by  their  presence ;  the  antero-posterior  one 
is,  perhaps,  a  little  abridged  by  the  thickness  of  the  vesical  walls,  uterus 
and  soft  parts  that  line  the  posterior  face  of  the  symphysis  and  anterior  sur- 
face of  the  sacrum,  the  oblique  diameters  alone  remaining  unchanged  ;  the 
location  of  the  rectum,  however,  on  the  left,  shortens  slightly  the  corre- 
sponding diameter. 

The  modification  of  the  transverse  diameter,  produced  by  the  psoas  mus- 
cles, is  always  much  less  when  these  are  in  a  state  of  relaxation  from  the 
flexure  of  the  thighs.  Finally,  as  Baudelocque  has  remarked,  the  bis-iliac 
diameter  is  diminished  in  length,  in  proportion  to  the  thickness  of  these 
muscles,  and  the  antero-posterior  one  being  more  contracted,  the  strait  be- 
comes more  elliptic  or  rounded.  Two  muscles  are  also  found  on  each  side 
of  the  excavation,  covering  the  obturator  and  ischiatic  foramina;  namely, 
the  obturator  internus,  and  the  pyramidales.    Flamand  attributes  the  move- 


Pelvis,  with  the  soft  parts  seen  from  above. 
A.  A  section  of  the  aorta.  B.  The  vena  cava  inferioi 
C.  The  internal  iliac  artery,  arising  together  witli  D,  the  ex- 
ternal iliac,  from  the  primitive  iliac  trunk.  E.  External  iliac 
vein.  f.  The  iliacus  internus.  and  o,  the  psoas  magnus  mus- 
cles. H.  The  rectum.  I.  The  uterus  with  its  appendages. 
K.  The  bladder,  the  fundus  of  which  is  depressed  so  as  to 
bring  the  womb  into  view. 


56 


FEMALE  ORGANS  OF  GENERATION. 


ments  of  rotation,  executed  by  the  head  in  the  pelvis,  to  the  action  of  these 
muscles ;  but  the  same  reasons  that  caused  us  to  reject  the  influence  of  the 
inclined  planes  on  this  process,  equally  deter  us  from  entertaining  the 
opinion  of  the  Strasburg  Professor.  The  pelvic  cavity  is  still  further 
diminished  by  the  rectum,  bladder,  and  cellular  tissue;  more  especially 
when  the  latter  is  loaded  with  fat.  Consequently,  the  foetal  head  descends 
with  more  difficulty  in  very  corpulent  women  than  in  others. 

The  perineal  strait,  although  open  in  the  dried  skeleton,  is  here  occupied 
by  a  sort  of  contractile  concave  partition,  which  sustains  the  viscera  of  the 
pelvic  and  abdominal  cavities.  This  floor,  so  to  speak,  is  composed  of  two 
muscular  planes  ;  the  interior  of  which,  formed  by  the  levator  ani  and  coccy- 
geal muscles,  is  concave  above;  and  the  other,  having  its  concavity  below, 
is  constituted  by  the  sphincter  ani,  the  transversus  perinei,  the  ischio-cavern- 
ous,  and  the  constrictor  vaginae  muscles.  The  internal  pudic  vessels  and 
nerves,  a  large  amount  of  cellular  tissue,  the  skin,  the  pelvic  aponeurosis, 
and  an  inter-muscular  aponeurosis  complete  this  floor,  which,  in  the  hour 
of  labor,  ought  to  become  thin  and  distended,  but  which  occasionally  offers 
such  an  obstacle  to  the  spontaneous  delivery  of  the  foetus  as  to  require  the 
intervention  of  art. 

The  extent  of  the  perineum,  in  its  ordinary  condition,  is  three  inches, 
namely :  from  the  point  of  the  coccyx  to  the  anus,  there  are  one  and  three- 
quarter  inches,  and  from  the  anus  to  the  vulva,  one  and  one-quarter  inches  ; 
but  at  the  instant  of  the  passage  of  the  head  through  the  genital  fissure  it 
becomes  so  distended,  that  the  interval  separating  the  anterior  commissure 
from  the  coccyx,  is  increased  from  four  to  four  and  three-quarter  inches. 

It  must  now  be  evident  that  the  terminal  outlet  of  the  pelvic  canal,  in  the 
pelvis,  covered  with  its  soft  parts,  is  not  at  the  point  of  the  coccyx,  but 
rather  at  the  anterior  commissure  of  the  perineum  ;  in  fact,  the  latter  is  so 
greatly  distended  in  the  last  moments  of  labor,  that  its  anterior  border  goes 
beyond  the  inferior  part  of  the  symphysis  pubis,  thereby  prolonging  very 
considerably  the  posterior  wall  of  the  pelvic  excavation,  and,  as  a  conse- 
quence, the  canal  to  be  traversed  by  the  foetus.  Wherefore,  the  direction 
in  which  the  head  is  ultimately  disengaged  is  not  represented  by  the  axis  of 
the  inferior  strait,  but  by  that  of  a  plane  vhich  may  be  drawn  from  the 
lower  part  of  the  symphysis  to  the  anterior  commissure  of  the  distended 
perineum. 

Hence,  in  order  to  form  an  exact  idea  of  the  line  traversed  by  the  foetus, 
from  its  entrance  into  the  superior  strait  until  its  final  exit  from  the  vulva, 
it  will  be  necessary  to  continue  the  operation  already  pursued  upon  the 
anterior  face  of  the  sacrum  (see  page  52)  over  the  curve  represented  by  the 
anterior  face  of  the  distended  perineum  :  that  is,  to  make  a  series  of  planes 
from  the  point  c  (Fig.  15)  to  the  divers  parts  of  the  perineal  curve ;  and, 
from  the  centre  of  each,  raise  a  perpendicular,  so  as  to  form  by  their  union 
a  complete  axis,  the  upper  extremity  of  which  is  the  axis  of  the  superior 
strait;  the  middle  part,  a  curved  line,  having  its  concavity  anterior  and  its 
convexity  parallel  to  the  front  face  of  the  sacrum  and  perineum,  and  the 
inferior  extremity  directed  from  before  backwards,  and  slightly  from  above 
downwards. 


- 


EXTERNAL  ORGANS  OF  GENERATION. 


57 


It  must  not,  however,  be  forgotten,  that  the  direction  just  described  be- 
longs to  the  vertical  posture,  and  that  it  becomes  remarkably  altered  in  the 
various  attitudes  assumed  by  the  female.  Thus,  whilst  lying  upon  the 
back,  as  is  usual  in  France  during  labor,  the  plane  of  the  superior  strait 
instead  of  looking  upward  and  forward  will  be  turned  upward  and  back- 
ward, and  its  axis  directed  from  above  downward  and  from  behind  forward. 
At  the  same  time,  the  plane  of  the  inferior  strait,  which  before  looked  back- 
ward and  downward,  will  be  turned  almost  directly  forward,  its  axis  also 
passing  directly  from  before  backward.  Finally,  the  terminal  orifice  formed 
by  the  contour  of  the  vulva  presents  another  plane,  which  at  the  moment 
of  delivery  (the  horizontal  position  being  still  maintained)  is  directed  up- 
ward and  forward.     In  short,  the  central  line  followed  by  the  foetus  during 


\ 


--X2 


7 


58  FEMALE     ORGANS     Oif     GENERATION. 

ARTICLE    I. 

MONS   VENERIS. 

The  mom  veneris  is  a  rounded  eminence,  a  species  of  relief,  more  or  lesa 
prominent  according  to  the  embonpoint  of  the  individual,  situated  in  front 
of  the  pubis,  and  surmounting  the  vulva ;  this  eminence  is  partly  produced 
by  the  bones,  and  partly  by  the  subcutaneous  adipose  tissue;  the  skin 
covering  it  is  very  thick  and  elastic,  but  being  little  extensible,  it  cannot 
aid  in  the  enlargement  of  the  vulva,  as  asserted  by  M.  Moreau,  at  the 
period  of  delivery.  In  the  adult  female,  it  is  covered  with  hair,  and  con 
lains  a  great  number  of  sebaceous  follicles. 

ARTICLE   II. 

VULVA. 

The  vulva  is  a  longitudinal  opening  or  fissure,  situated  on  the  median 
-  at  *e  base  of  the  trunk :  be?n<-  '  I  ir  *Vont  by  the  mons  veneris, 

,;ng  thereto, 


EXTERNAL  ORGANS  OF  GENERATION.  59 

They  consist  of  a  cutaneous  and  a  mucous  layer,  between  which  is  a 
Bbrous  partition,  a  continuation  of  the  superficial  fascia  of  the  perineum. 
Between  this  aponeurosis  and  the  internal  surface  of  the  integument,  is 
found  a  very  thick  layer  of  cellulo-adipose  tissue,  filling  up  a  peculiar 
pouch  hitherto  unknown  to  anatomists  until  discovered  by  M.  Broca. 

[This  pouch  is  constituted  by  a  membranous  sac  situated  between  the  skin  and 
the  superficial  aponeurosis :  its  bottom  is  directed  towards  the  fourchette,  where 
it  becomes  blended  with  the  fascia  superficialis  of  the  parts  on  each  side  of  the 
anus.  It  has  a  long  and  narrow  neck,  which  is  directed  toward  the  external 
inguinal  ring,  and  receives  into  its  opening  a  portion  of  the  fibres  of  the  round 
ligament.  Its  cavity  is  filled  with  cellulo-adipose  tissue,  varying  in  quantity  with 
the  embonpoint  of  the  individual.  The  pouch  forms  of  itself  the  greater  part  of 
the  thickness  of  the  labia  majora. 

The  fibres  of  which  the  pouch  is  composed  are  derived  chiefly  from  the  fascia 
superficialis  of  the  thigh  and  abdomen,  but  some  proceed  directly  from  the  spine 
of  the  pubis;  the  most  external  are  attached  to  the  rami  of  the  pubes  and  ischia, 
whilst  the  most  internal  unite  and  become  blended  with  the  suspensory  ligament 
of  the  clitoris. 

According  to  M.  Broca,  this  sac  is  the  analogue  of  the  dartos  of  the  male ;  M. 
Sappey,  however,  believes  that  it  is  comparable  only  to  the  suspensory  ligament 
of  the  scrotum  and  penis.  The  microscope  proves  it  to  be  composed  of  interlaced 
fibres  of  elastic  tissue. 

The  arteries  of  the  labia  majora  are  derived  from  the  perineal  artery,  itself  a 
branch  of  the  internal  pudic  or  of  the  external  pudic  or  epigastric. 

The  veins  for  the  most  part  accompany  the  arteries,  some,  however,  pass  back- 
ward and  form  a  plexus,  which  communicates  with  the  bulb  and  vaginal  veins. 
These  veins,  which  are  very  numerous,  often  become  dilated  during  pregnancy. 

The  nerves  proceed  from  the  genito-crural  branch  of  the  lumbar  plexus,  and 
from  the  perineal  branch  of  the  internal  pudic  nerve.  The  lymphatics  all  pass 
into  the  inguinal  glands.] 

2.  The  nymphoz,  or  labia  interna,  are  brought  into  view,  by  separating 
the  external  lips,  under  the  form  of  two  mucous  folds,  resembling  the  comb 
of  a  young  cock.  Contracted  behind,  where  they  are  continuous  with  the 
internal  face  of  the  labia  externa,  they  spread  out  in  front  as  they  con- 
verge towards  each  other.  These  lips  scarcely  descend  to  the  middle  of 
the  external  ones,  but  they  mount  up  in  front  as  high  as  the  clitoris,  where 
they  bifurcate;  the  inferior  branch  of  this  bifurcation  is  lost  in  the  clitoris; 
but  the  other  surmounts  it,  joins  its  fellow  of  the  opposite  side,  and  forms 
above  this  body  a  little  fold  in  the  shape  of  a  hood,  called  the  prepuce  of 
the  clitoris.  At  birth,  the  nymphse  project  beyond  the  external  lips,  but  at 
puberty  they  are  concealed  by  the  latter.  Again,  they  become  visible  in 
child-bearing  women ;  rather,  however,  by  the  separation  of  the  labia 
majora  than  by  their  own  prominence. 

Further,  their  dimensions  are  very  variable  in  different  individuals,  and 
in  various  climates  ;  thus,  in  certain  countries  of  Africa,  they  are  very  long, 
and  constitute  the  famous  apron  of  the  Hottentots.  Besides,  as  Velpeau 
has  remarked,  these  parts  are  so  extensible  that,  under  the  influence  of 
continual  tractions,  they  may  become  very  much  elongated.  I  have  met 
wi'.h  a  young  female    in  my  own  practice,  who  was  afflicted  with  an  ex- 


60  FEMALE  ORGANS  OF  GENERATION. 

cessive  itching  at  the  vulva  at  the  commencement  of  her  pregnancy.  To 
relieve  this,  she  was  in  the  habit  of  scratching  continually,  and  in  her  im- 
patience dragged  on  the  right  nympha,  so  that,  in  less  than  a  fortnight,  it 
had  become  twice  as  long  as  its  fellow. 

[The  internal  labia  are  covered  with  tesselated  epithelium,  below  which  are 
papillae  whose  sensibility  is  especially  exercised  during  copulation.  The  papillae  of 
the  internal  surface  have  a  greater  development  than  those  of  the  external  surface, 
and  their  size  is  found  to  increase  as  they  approach  the  orifice  of  the  vagina. 

The  blood-vessels  of  the  internal  labia  are  supplied  by  those  of  the  labia  inajora 
A  portion  of  the  veins  anastomose  largely  with  those  of  the  bulb  and  of  the 
vagina. 

The  nerves  come  from  the  perineal  branch.  The  lymphatics  proceed  to  the 
inguinal  glands.] 

3.  The  Clitoris. —  Under  this  name,  a  little  erectile  tubercle,  resembling 
the  corpus  cavernosum  of  the  male  (except  iu  volume),  is  described.  Its  free 
extremity  appears  at  the  front  part  of  the  vulva,  about  half  an  inch  behind 
the  anterior  commissure  of  the  labia  externa,  and  its  body  is  attached  by 
two  crura  to  ischio-pubic  rami ;  these  roots  ascend,  converging  and  increas- 
ing in  size,  to  the  level  of  the  symphysis,  where  they  unite  to  form  a  single 
cavernous  body,  flattened  on  its  sides,  which  after  a  course  of  two  or  three 
lines  in  front  of  the  symphysis,  becomes  detached  and  curved  forward  so 
as  to  present  a  convexity  above  and  in  front,  at  the  same  time  growing 
more  and  more  slender  towards  the  free  extremity,  which  is  called  the  glana 
clitoridis. 

During  the  first  months  of  the  intra-uterine  life  it  is  difficult  to  make 
out  the  distinction  of  the  sexes,  because  the  clitoris  is  as  long  as  the  penis ; 
even  in  the  earlier  years  of  existence  its  dimensions  are  quite  considerable, 
but  after  this  period  it  ceases  to  grow,  and,  in  some  females,  apparently 
diminishes.  Again,  in  certain  rare  cases,  it  acquires  a  great  length  ;  for 
instance,  M.  Cruveilhier  has  seen  one  whose  free  extremity  measured  two 
inches,  and  a  case  is  on  record  where  it  reached  from  four  and  a  quarter  to 
five  inches.  Most  of  the  pretended  hermaphrodites  may  be  referred  to 
anomalies  of  this  kind. 

Henle  gives  a  representation  of  a  case  so  singular  and  rare  as  to  deserve 
mention.  It  is  a  congenital  division  of  the  clitoris  occurring  in  a  girl  of 
seventeen  years  of  age,  in  which  the  body  of  that  organ  was  completely 
divided  through  the  middle  so  as  to  form  two  nipples,  each  invested  with  a 
prepuce.  The  halves  of  the  prepuce  thus  divided,  are  prolonged  respec- 
tively toward  the  corresponding  nympha,  from  which  it  is  separated  by  a 
notch,  and  is  lost,  above,  in  the  frenum  clitoridis. 

The  clitoris,  like  the  penis,  has  a  suspensory  ligament,  and  an  erector 
muscle;  the  canal  of  the  urethra  in  the  female  passes  between  the  two 
branches  of  the  cavernous  body,  as  it  does  iri  the  male. 

[The  structure  of  the  clitoris  is,  in  all  respects,  precisely  that  of  the  corpus  cav- 
ernosum  of  1 1 1 •  >  male,  except  in  point  of  size.  It  presents  the  fibrous  envelope,  the 
muscular    trabecule,   ami    the    heliciue.    arteries,  all   characteristic    of    the    erectile 


EXTERNAL  ORGAN'S  OF  GENERATION.  61 

cissue.  During  coiuon,  blood  accumulates  in  it,  dilates  it,  and  thereby  causes 
it?  erection. 

The  arteries  of  the  clitoris  come  from  the  perineal  artery,  and  are  distributed  aa 
in  the  male,  presenting  therefore  the  cavernous  artery,  which  on  each  side  enters 
the  corresponding  corpus  cavernosum,  and  the  dorsal  artery,  which  is  distributed 
to  the  mucous  membrane  known  as  the  prepuce  of  the  clitoris. 

The  veins  form  a  plexus  arranged  in  two  planes,  the  most  superficial  of  which 
furnishes  the  dorsal  vein,  whilst  the  deeper  communicates  with  the  veins  of  the 
bulb,  of  the  vagina,  and  of  the  bladder. 

The  nerves  proceed  from  the  perineal  branch  of  the  internal  pudic;  the.  y  send 
branches  to  the  corpus  cavernosum,  and  terminate  in  the  prepuce,  which  is  the 
principal  seat  of  voluptuousness  in  the  female.] 

4.  The  vestibule  is  a  small  triangular  space  placed  at  the  upper  pirt  of 
the  vulva.  It  is  bounded  above  by  the  clitoris,  below  by  the  urethra,  and 
laterally  by  the  nymphse. 

5.  The  Urethra.  —  The  meatus  urinarius  is  situated  just  below  the  ves- 
tibule, about  an  inch  from  the  clitoris,  and  immediately  above  the  promi- 
nent enlargement  of  the  anterior  part  of  the  vagina.  The  orifice  is  usually 
more  contracted  than  the  canal,  but  the  tubercle  or  enlargement  just 
alluded  to,  enables  us  to  sound  females  without  uncovering  them,  for  it  is 
only  necessary  to  recognize  it  by  the  finger  in  order  to  direct  the  instru- 
ment properly.  In  my  estimation,  the  following  is  the  most  simple  method 
of  introducing  the  catheter  without  uncovering  the  patient ;  1  first  intro- 
duce my  finger  into  the  orifice  of  the  vagina,  and  rest  its  palmar  face 
against  the  anterior  vaginal  wall ;  I  then  slide  the  instrument  along  this 
palmar  face  until  it  is  arrested  by  the  fold  already  alluded  to;  then  I 
depress  the  extremity  so  as  to  elevate  the  point  of  the  instrument  one  or 
two  lines,  and  in  the  majority  of  cases,  the  canal  is  easily  entered  in  this 
manner. 

[If  the  first  attempt  should  fail,  it  may  be  tried  again  in  another  way.  The 
point  of  the  forefinger  finds  the  clitoris,  and  passes  from  above  downwards  to  the 
middle  of  the  vestibule;  the  first  inequality  met  with  is  the  orifice  of  the  urethra, 
into  which  the  instrument  can  then  be  inserted.  I  have  often  succeeded  in  this 
way,  after  having  failed  by  the  ordinary  method. 

In  some  women,  those  especially  who  have  borne  children,  the  parts  adjoining 
the  meatus  are  so  deformed,  that  it  becomes  absolutely  necessary  to  expose  the 
parts  in  order  to  introduce  the  catheter;  even  then  it  is  by  no  means  easily  done, 
and  I  have  seen  the  most  skilful  foiled  in  attempting  it.  It  may  be  accomplished 
with  certainty  by  separating  carefully  the  greater  and  lesser  labia,  and  then 
sliding  the  extremity  of  the  catheter  from  above  downward  along  the  median  line 
of  the  vestibule  below  the  clitoris,  which  is  the  chief  rallying  point.  During  this 
movement  the  instrument  falls,  so  to  speak,  of  its  own  accord  into  the  orifice  of 
the  urethra  ;  but  if  slid  either  to  the  right  or  left,  it  will  be  sure  to  go  astray. 
We  shall  learn  hereafter  (article  Pregnancy)  the  cause  of  the  difficulties  met  with 
in  catheterizing  pregnant  women.] 

The  urethra,  a  continuation  of  the  meatus  urinarius,  just  described, 
varies  in  the  female  from  one  to  one  and  a  half  inches  in  length.  It  is 
large,  conical,  and   slightly   curved.     Its   inferior   portion    is    confounded 


62 


FEMALE  ORGANS  OF  GENERATION". 


with,  or  at  least  intimately  united  to,  the  anterior  vaginal  wall,  and  its 
anterior  parietes,  separated  in  front  from  the  pubis  by  some  cellular  tissue 
only,  is  located  on  a  level  with  the  symphysis,  under  the  junction  of  the 
two  crura  of  the  clitoris. 

The  canal  of  the  urethra  is  muscular  and  erectile,  having  a  thick  lamina 
of  muscular  fibres,  which  seem  to  be  a  continuation  of  those  of  the  blad- 
der ;  another  thick  layer  formed  by  a  venous  plexus,  lies  subjacent  to  the 
mucous  membrane. 

Occasionally,  this  canal  is  enormously  dilated.  Flamand  met  with  a  case 
that  permitted  the  introduction  of  the  finger,  and  Meyer,  with  another, 
which  eventually  admitted  of  coition  ! 

6.  TJie  Hymen.  —  The  irregular  opening  of  the  vagina  is  found  beneath 
the  meatus  urinarius ;  it  is  of  variable  dimensions  after  coition,  and  in 
females  who  have  had  children ;  but  in  virgins,  it  is  provided  with  a  mem- 
brane by  which  the  orifice  is  diminished.  This  membrane  is  the  hymen, 
a  species  of  diaphragm,  interposed  between  the  internal  organs  and  the 
external  genital  apparatus  and  the  urinary  passages.  It  resembles  a  crescent 
in  shape  (Fig.  19),  the  concavity  being  anterior ;  sometimes  the  horns  of 
the  crescent  are  prolonged  enough  to  join  each  other,  thus  forming  a  com- 
plete circle,  perforated  in  the  centre  (Fig.  20)  ;  its  free  margin  is  thin  and 
concave ;  the  convex  one  is  continuous  with  the  membrane  of  the  vagina  or 
vulva,  and  as  this  blocks  up  the  posterior  and  lateral  parts  of  the  v<  gina, 
a  notable  difference  will  exist  in  the  extent  of  the  orifice,  dependent  upon 
the  greater  or  less  size  of  the  hymen. 

Sometimes  the  hymen  forms  a  complete  imperforate  membrane.  Tt  <ugh 
often  thin,  transparent,  and  very  fragile,  it  is  occasionally  found  thiol  «\n<l 
resisting. 

Fia.  19.  Fia.  20. 


Fif).  19.    Hymen  in  the  form  of  a  crescent. 

a.  Clitoris.    B.  Labia  externa.    0.  Labia  interna.    D.  Orifice  of  the  uretlira.    B.Hymen,    f.  Orifice 
of  the  vagina,    o.  Posterior  commissure  of  the  vulva. 

Fio.  20.    This  figure  exhibits  the  hymen  iu  the  form  of  a  circle,    e.  The  hymeu.     f.  The  central 
opening  somewhat  elonguted. 


EXTERNAL  ORGANS  OF  GENERATION.  G3 

The  two  forms  just  mentioned  are  not  the  only  ones  which  the  hymen 
may  assume;  other  varieties  have  been  described  by  M.  Velpeau,  as  follows: 
1.  In  the  semicircular  species,  the  hymen  may  form  such  a  narrow  and 
solid  fold  as  to  permit  copulation  without  being  ruptured.  2.  In  the  cres- 
centic  variety  (Fig.  19)  the  concave  border  approaches  more  or  less  towards 
the  urethra,  in  such  a  way  as  to  contract  the  vagina  behind,  and  hence  it 
almost  always  gives  way  in  coition.  3.  In  the  circular  variety,  the  free 
border  is  much  thinner  than  the  other  (Fig.  20),  often  being  fringed,  as  it 
were,  and  leaving  an  opening  which  is  sometimes  round,  sometimes  slightly 
elongated,  though  in  general  situated  somewhat  nearer  to  the  anterior  than 
the  posterior  wall  of  the  vagina.  4.  Again,  we  find  a  disk  or  complete 
diaphragm,  that  is  ordinarily  pierced  by  a  number  of  small  holes  like  those 
of  a  watering-pot,  and  at  other  times  is  without  the  least  aperture.  5.  In 
some  instances  a  species  of  bridle,  or  a  small  cord  attached  under  the  urethra, 
or  on  the  concave  border  of  the  hymen,  supplants  both  the  valve  and  the 
circle.     6.  Lastly,  a  second  hymen  occasionally  exists  above  the  first. 

This  membrane  is  regarded  as  the  seal  of  virginity ;  and  yet,  as  just 
shown,  it  is  often  found  after  a  fecundation  ;  and,  on  the  other  hand,  numer- 
ous causes  besides  coition  may  destroy  it.  It  is  generally  ruptured  at  the 
first  sexual  approaches,  and  of  its  debris  are  formed  two  or  three  little 
tubercles,  bearing  the  name  of  carunculce  myrtiformes. 

Parturition  generally  destroys  the  posterior  and  inferior  segments  of  the 
hymen,  the  carunculce  myrtiformes  slough  away,  and  only  the  small  superior 
fringes  remain.  This  condition  serves  as  a  generally  reliable  means  of  dis- 
tinguishing between  the  vulva  of  a  woman  who  has  borne  children  and  a 
nulliparae,  where  the  hymen  is  merely  torn  and  can  be  restored  to  its 
virginal  shaj:>e  by  approximating  its  edges.    (See  Plate  xii.) 

The  hymen  is  composed  of  a  fold  of  mucous  membrane,  containing 
between  its  laminae  a  few  vessels  and  some  areolar  tissue. 

7.  The  carunculce  myrtiformes  are  some  little  tubercles,  two  to  five  in 
number,  which  appear  to  be  the  debris  of  the  ruptured  hymen ;  the  two 
most  anterior  ones,  according  to  certain  physiologists,  appertain  to  the 
median  columns  of  the  vagina. 

In  consequence  of  oft-repeated  friction,  these  caruncles  may  inflame, 
degenerate,  and  even  become  the  source  of  an  abundant  purulent  discharge  ; 
they  have  been  mistaken  under  such  circumstances  for  syphilitic  vegetations, 
and  the  patient  subjected  to  anti-venereal  treatment,  which,  at  least,  was 
useless.  Personal  cleanliness,  and  some  of  the  vegeto-mincral  lotions  are 
usually  sufficient  to  cause  their  disappearance.  M.  Velpeau  has  resorted, 
however,  in  some  cases,  to  excision. 

8.  Fossa  Navicularis. — This  is  a  little  depression,  of  half  an  inch  only  in 
extent,  bounded  behind  by  the  fourchette,  and  in  front  by  the  convex 
border  of  the  hymen.  It,  like  the  fourchette,  formed,  as  before  stated,  by 
the  junction  of  the  inferior  extremities  of  the  labia  majora,  mostly  disappea?  u 
after  delivery. 


64  FEMALE  ORGANS  OF  GENERATION". 


ARTICLE  III. 

OF   THE   SECRETORY  APPARATUS   OF  THE    EXTERNAL    ORGANS    OF 
GENERATION. 

[The  secretory  apparatus  of  the  female  genital  organs  has  been  the  subject  of 
numerous  investigations,  but  of  late  a  fresh  interest  in  the  subject  has  given  rise  to 
works  bj  Robert,  lluguier,  Sappey,  Martin,  and  Leger,  all  of  which  are  placed 
under  contribution  in  the  preparation  nf  tins  article. 

Aside  from  the  piliferous  bulbs,  the  glands  of  the  vulva  may  be  arranged  in 
three  classes:  1.  Sudoriparous  glands;  2.  Sebaceous  glands;  3.  Muciparous 
glands  and  follicles. 

First  class. — The  sudoriparous  glands  are  found  on  the  penil  and  the  external 
surface  of  the  labia  major  a  ;  they  are  mingled  with  the  sebaceous  glands  and 
surround  the  bases  of  the  hair  bulbs.  Presenting  the  same  arrangement  as  in 
other  parts  of  the  body,  they  are  noticeable  here  on  account  of  their  great  number. 

Second  class.  —  The  sebaceous  glands  of  the  vulva  are  extremely  numerous. 
Those  of  the  mons  veneris  and  of  the  outer  surface  of  the  labia  majora  are  remark- 
able for  their  size,  having  an  average  diameter  of  Tgff  of  an  inch.  They  are 
generally  composed  of  from  four  to  six  lobules,  each  containing  eight  or  ten  culs~ 
desac.     They  always  open  upon  a  piliferous  bulb. 

The  internal  surfaces  of  the  labia  majora  are  also  provided  with  sebaceous  glands 
to  the  extent  of  about  forty  to  every  'i  of  an  inch  square.  They  are  still  more 
numerous  upon  both  sides  of  the  lesser  labia,  the  inner  surfaces  of  which  present 
about  one  hundred  and  fifty  to  every  §  of  an  inch  square.  Martin  and  Leger  note 
the  fact,  that  these  glands,  which  are  very  apparent  in  the  adult  female,  become 
atrophied  after  the  cessation  of  the  menstrual  function,  and  cannot  be  found  at  all 
in  the  foetus. 

The  sebaceous  glands  are  also  found  on  the  fourcbette  and  the  prepuce  of  the 
clitoris.  No  trace  of  them,  however,  is  to  be  discovered  either  in  the  vestibule  or 
around  the  orifice  of  the  urethra. 

These  glands  secrete  an  oily  matter,  which  maintains  the  suppleness  of  the  parts 
to  which  it  is  applied,  prevents  them  from  contracting  abnormal  adhesions,  and 
preserves  them  from  irritation  by  the  urine. 

Third  class.  —  The  muciparous  follicles  as  described  by  M.  lluguier,  present  two 
varieties:  in  the  first,  they  are  i.solated  or  simply  agminated,  isolated  or  agminated 
follicles;  in  the  second  they  are  enclosed  in  one  envelope,  and  discharge  into  the 
same  excretory  canal,  vulvo-vaginal  glands. 

A.  Isolated  or  agminated  muciparous  follicles.  These  follicles  exist,  according  [*\ 
lluguier,  upon  several  points  of  the  circumference  of  the  vaginal  orifice  ;  they  are 
sometimes  absent  and  always  difficult  to  discover;  their  existence  even  has  been 
denied  by  some  anatomists  (Sappey,  Martin,  Leger).  lluguier  describes  three 
groups  of  them. 

1.  —  Eight  or  ten  of  them  are  found  in  the  vestibule  below  the  clitoris,  where 
they  open  by  separate  orifices,  which  are  very  small  and  partly  covered  by  a  root 
of  valve  easily  raised  by  a  probe;  (Vestibular  follicles  of  lluguier)  (fig.  21,  A). 
These  follicles  arc  mere  depressions  in  the  mucous  membrane  without  a  diverticu- 
lum. So  simple  is  their  structure,  that  Martin  and  L6ger  refused  to  call  them 
muciparous  follicles. } 

2.  Other?,  termed  urethral  follicles  on  account  of  their  situation,  are  stated 
by  M.  Huguier  to  be  less  readily  discoverable  than  the  preceding,  on  which 
account  they  were  supposed  by.  M.  Robert  to  be  less  numerous.     They  are 


EXTERNAL    ORGANS    OF    GENERATION. 


65 


of  considerable  size,  and  are  situated  at  a  depth  of  from  three-eighths  to 
four-eighths  of  an  inch  in  the  cellulo-vascular  tissue  of  the  urethra  (Fig. 
21,  c).  They  are  placed  beneath  the  mucous  membrane  in  a  direction 
parallel  to  the  canal,  and  discharge  in  close  proximity  to  the  orifice  of  the 
urethra  upon  the  surface  of  the  projection  which  Fw.21. 

forms  the  inferior  boundary  of  that  opening 
in  such  a  way  as  to  form  a  semicircle,  or  some- 
times even  an  entire  circle,  around  it.  They 
are  closer  together  than  those  which  have  been 
just  described,  and  sometimes  several  of  them 
open  into  the  same  excretory  cavity,  so  as  to 
produce  the  ramified  arrangement  which  Graaf 
has  figured  and  described. 

3.  Laterally,  and  at  some  distance  from  the 
urethral  orifice,  are  several  small  and  shallow 
ones,  with  a  common  opening  at  the  bottom  of  a 
remarkable  conical  depression.  M.  Huguier 
states  that  these  are  often  absent,  and  he  pro- 
poses calling  them  the  lateral  urethral  follicles 
(Fig.  21,  b). 

4.  Besides  these,  some  two,  three,  or  four  large 
follicles  are  found  in  some  females  upon  the 

lateral  parts  of  the  vaginal  orifice,  immediately  below  the  hymen  or  the 
upper  carunculse  myrtiformes  (Fig.  21,  d)  ;  they  are  the  lateral  follicles  of 
the  orifice  of  the  vagina.  Their  openings  ordinarily  correspond  neither  in 
number,  situation,  nor  arrangement,  with  those  of  the  opposite  side ;  some 
are  slightly  projecting  whilst  others  are  not  so,  and  some  are  readily  visible 
whilst  others  are  hidden  beneath  the  myrtiform  caruncles. 

b.  Vulvo-vaginal  gland.  —  This  gland  had  been  completely  lost  sight  of  by 
modern  anatomists,  although  described  by  Gaspar  Bartholin ;  and  attention 
has  only  recently  been  called  to  it  by  M.  Huguier.  It  belongs  to  the  class 
of  conglomerate  glands.  There  are  two  vulvo-vaginal  glands,  one  on  each 
side,  where  they  form  peculiar  bodies  whose  position  it  is  important  to  define 
with  exactness.  They  are  situated  at  the  limits  of  the  vulva  and  vagina, 
upon  the  lateral  and  posterior  parts  of  the  latter,  about  three-eighths  of  an 
inch  above  the  upper  surface  of  the  hymen  or  of  the  myrtiform  caruncles, 
io  the  triangular  space  formed  on  each  side  by  the  juxtaposition  of  the 
lectum  and  vagina,  upon  the  latter  of  which  they  repose.  They  lie  at  a 
distance  of  from  three-eighths  to  five-eighths  of  an  inch  from  the  internal 
turface  of  the  ascending  rami  of  the  ischia,  and  from  three-quarters  of  an 
i  ich  to  one  and  a  quarter  inches  from  the  external  labia. 

The  vulvo-vaginal  gland  has  somewhat  the  shape  of  an  apricot-kernel, 
resembling  in  this  respect  the  lachrymal  gland ;  like  the  latter,  its  two 
surfaces  are  flattened,  and  it  is  besides  slightly  lobular  and  mamelonated. 
According  to  M.  Huguier,  it  is  much  flatter  in  women  who  have  borne 
children,  which  he  attributes  to  the  species  of  separation  which  its  granular 
dements  must  undergo  from  the  enormous  distention  of  the  vulva  during 
6 


66 


FEMALE  ORGANS  OF  GENERATION. 


Fio.  22. 


labor.     The  gland  of  the  right  side  does  not  always  resemble  that  of  the  left , 

it  is  indeed  not  uncommon  to  find  one  much  more  developed  than  the  other. 

Its  size  varies  much  according  to  age,  habits,  and,  adds  M.  Huguier, 

according  to  the  development  of  tho 
ovaries,  which  appear  to  exercise  a  de- 
cided influence  over  it ;  for  he  has  always 
found  the  largest  gland  upon  the  same 
side  with  the  most  voluminous  ovary. 
It  also  appears  larger  in  females  who 
indulge  immoderately  in  sexual  plea- 
sures. Its  size  is  greatest,  in  general, 
between  the  ages  of  sixteen  and  thirty- 
five  years.  Its  diameter  at  this  period 
of  life  is,  on  an  average,  from  four-eighths 
to  five-eighths  of  an  inch.  It  is  very 
small  at  puberty,  and  becomes  atrophied 
in  old  age. 

Excretory  Duct.  —  Each  of  the  gran- 
ules of  which  the  gland  is  composed,  is 
furnished  with  a  minute  duct,  which,  by 
uniting  with  those  of  the  neighboring 
granules,  gives  rise  to  three  separate 
ducts.  The  latter  soon  join  to  form  a 
single  canal,  which  proceeds  from  the 
internal  surface  and  vulvar  extremity 
of  the  gland  (Fig.  22,  D),  and  opens  in 
virgins,  or  in  females  in  whom  the  hymen 
has  been  only  dilated,  in  the  internal 
angle  which  the  great  circumference  of 
this  membrane  forms  by  its  union  with 
the  contour  of  the  vulvar  opening,  and,  when  the  hymen  has  been  ruptured, 
at  the  base  of  the  lateral  and  posterior  myrtiform  caruncles  (Fig.  22,  E). 
The  orifice,  which  is  smaller  than  the  duct  which  it  terminates,  is  in  most 
women  surrounded  by  a  vascular  area,  which  serves,  by  its  lively  red  color, 
to  distinguish  it  from  the  neighboring  parts.  If  required,  it  will  only  be 
necessary  to  turn  the  caruncle  inward  in  order  to  render  it  conspicuous . 
it  should  however  be  distinguished  from  three  or  four  minute  openings 
found  in  the  same  furrow,  and  which  belong  to  the  lateral  follicles  of  the 
orifice  of  the  vagina. 

The  direction  of  the  opening  of  the  duct  is  perpendicular,  but  its  oblicpie 
orifice  is  directed  upwards  and  inwards.  Its  external  semi-circumference  is 
provided  with  a  small  falciform,  valvular  fold  of  mucous  membrane,  which 
increases  the  difficulty  of  its  detection.  In  the  normal  condition  the  diameter 
of  the  orifice  hardly  exceeds  the  one-one-hundreth  of  an  inch. 

The  diameter  of  the  duct  varies  from  the  one-twenty-fourth  to  the  one- 
eighth  of  an  inch,  and  its  length,  which  lessens  as  the  gland  is  more  volu- 
minous and  approaches  near  the  in\  rlit'orm  caruncles,  is,  on  an  average, 
about  five-eighths  of  an  inch. 


Vulvovaginal  Gland. 
A  A.  Section  of  the  labia  majora  and  of  the 
nymphs,  showing  the  excretory  duct  and  its 
orifice.  B.  The  gland.  C.  Excretory  duct,  C. 
Stylet  engaged  in  the  orifice  of  the  excretory 
duct.  D.  Its  glandular  extremity.  E.  Its 
vulvar  extremity  and  orifice.  F.  Bulb  of  the 
vagina.    0.  Ascending  ramus  of  the  ischium. 


EXTERNAL  ORGANS  OF  GENERATION. 


67 


Uses  and  Functions.  —  The  vulvovaginal  gland,  like  the  entire  generative 
apparatus  of  which  it  forms  a  part,  acquires  its  full  development  only  at 
puberty.  This  concordance  alone,  independently  of  observation,  would  lead 
to  the  supposition  that  the  fluid  which  it  secretes  is  destined  to  bear  a  part 
in  the  generative  act. 

The  amount  of  its  secretion  is,  in  fact,  variable.  It  is  especially  increased 
during  sexual  intercourse,  illicit  contacts,  and  under  the  influence  of  lasciv- 
ious thoughts,  desires,  and  dreams.  When,  during  coition,  the  muscles  of 
the  perineum  and  vulva  are  excited  to  involuntary  and  convulsive  contrac- 
tions, it  is  expelled  in  an  intermittent  manner  or  by  jets,  as  is  the  sperm  in 
the  ejaculation  of  the  male.  According  to  M.  Huguier,  the  use  of  this 
abundant  secretion  is  to  lubricate  the  external  parts,  and  thus  render  the 
first  approaches  less  painful,  to  maintain  the  humidity  of  the  organs  during 
the  act,  and  thereby  preserve  their  extreme  sensibility. 

ARTICLE   IV. 


,\  H 


% 


PERINEUM  -J-  PERINEAL  FLOOR  —  PERINEAL  BODY. 

The  pelvic  floor  is  formed  by  sue-  iv..  220. 

cessive  layers  of  fasciae  and  muscles,  1  ^ 

which  are  pierced  by  the  anus,  vulva, 
and  urethra.     Beginning  externally,  Y  j* 

it  consists  of  the  external  cutaneous      , ' .,  J_        lj/fi 

tissue,  the  sub-cutaneous  cellular  tis-  ■  ',  . 

sue,  the  sub-peritoneal  tissue,  and  the     4 f-  Mmw  '  f    I   '"' 

peritoneum.  The  space  between  the 
vagina  and  rectum  is  occupied  by  a 
structure  peculiar  to  the  female, 
which  is  known  as  the  'perineal  body. 
It  is  a  point  of  attachment  for  a  num- 
ber of  fasciae,  which,  midway  between 
the  posterior  vulvar  commissure  and 
the  anus,  are  fused  together  with  con- 
nective tissue  and  elastic  fibres,  form- 
ing an  elastic  and  extensible  structure, 
upon  which  the  integrity  of  the  parts 
depends  in  the  last  stage  of  labor. 

The  perineal  body  is  triangular  in 
shape.  The  apex  extends  a  little 
above  the  noddle  of  the  vagina.     The 

base  of  the  triangle  forms  the  interior    coccygeus.    12.  Obturator  externus. 
plane  covered  by  the  skin,  separating  the  vulva  from  the  anus,  and  is  known 
as  the  perineum. 

It  is  from  an  inch  to  an  inch  and  a  half  long.  During  labor,  the  fetal 
head,  forced  down  by  t  lie  uterine  contractions  upon  the  perineal  body,  dilates 
the  vagina,  compresses  the  rectum  behind  ami  the  bladder  in  front,  bulges 
the  perineum,  and  stretches  it  from  three  to  live  inches. 


"-  ■-£. 


Muscles  of  the  Female  Perineum  (Pnvage). 
i.  Anus.  b.  Bulb  of  vagina,  c.  Coccyx.  L.  Larger 
sacro-sciatic  ligament,  p.  Perineal  body.  u.  Urethra. 
a.  Vagina,  g.  Vulvo-vaginal  gland.  1.  Clitoris.  2, 
Its  suspensory  ligament.  8.  Crura  clitoridis.  4.  Erec- 
tor clitoridis  muscle.  •"'.  Bulbo-cavernosus  muscle.  7. 
Superficial  transverse  muscle.  8.  Sphincter.  '.'.  Pubo- 
ns  muscle.  10.  Obturato-coccygeus.  11.  Ischio- 


Q8  FEMALE  ORGANS  OF  GENERATION. 

CHAPTER   III. 

OF  THE   INTERNAL  ORGANS   OF   GENERATION. 

TnE  internal  organs  of  generation  are  the  vagina  and  the  uterus,  together 
■vith  its  appendages,  the  Fallopian  tubes  and  ovaries. 

ARTICLE   I. 

OF   THE   VAGINA. 

The  vagina,  or  vulvo-uterine  canal,  is  a  cylindrical  membranous  tube, 
extending  from  the  vulva  to  the  uterus ;  it  is  situated  in  the  pelvic  excava- 
tion between  the  bladder  and  rectum ;  extending  from  the  vulva  to  the 
Huperior  strait,  it  has  of  course  the  same  direction  as  the  general  axis  of  the 
pelvis:  that  is,  it  forms  a  curve,  the  concavity  of  which  is  anterior;  the 
walls  are  soft  and  yielding,  flattened  from  before  backwards,  with  their  sur- 
faces in  contact.  Its  length  varies  from  four  and  a  quarter  to  five  and  a 
quarter  inches,  though,  according  to  Professor  Velpeau  (Lemons  Orales),  it 
is  much  less  than  has  been  generally  imagined,  or  than  he  himself  has 
pointed  out  in  his  works,  being  hardly  two  and  a  quarter  to  two  and  three- 
quarter  inches  long.  Although  this  remark  may  be  true,  if  the  length  be 
measured  in  the  dead  subject,  where  the  soft  flabby  walls  of  the  vagina 
<asily  yield  under  their  own  weight  and  that  of  the  uterus,  and  in  conse- 
quence, the  vertical  extent  of  this  cavity  does  not  exceed  three  or  three  and 
f.  half  inches ;  yet,  the  elasticity  of  these  walls  will  permit  the  introduction 
of  a  speculum  five  or  six  inches  long,  and  when  the  uterus  is  raised  com- 
pletely above  the  superior  strait,  the  estimate  of  the  Professor  of  La  Charite 
is  certainly  below  the  truth. 

The  length  of  the  vagina  varies  in  different  females  ;  thus,  for  instance, 
die  negress  has  it  longer  and  more  spacious  than  the  European,  as  a  general 
rule.  Professor  Chomel  informed  me  that  he  had  frequently  remarked  this 
fact,  and  I  have  since  had  occasion  to  verify  its  truth  ;  nor  is  the  vagina 
uniform  in  its  size,  in  all  parts  of  its  extent ;  for  the  inferior  orifice  is  the 
most  contracted,  the  superior  extremity  is  the  largest,  whilst  the  middle 
part,  especially  in  women  who  have  had  many  children,  frequently  exhibits 
a  considerable  extension.  The  walls  apparently  retract  in  aged  females, 
and  greatly  diminish  the  area  of  its  cavity,  returning  very  nearly  to  the 
same  dimensions  as  are  found  in  young  girls. 

This  canal  is  sometimes  very  short,  reduced  even  to  one  and  a  half  or 
two  inches ;  but  this  congenital  brevity  must  not  be  confounded  with  the 
apparent  shortening  produced  by  the  descent  of  the  uterus. 

M.  Cruveilhier  says  these  cases  are  daily  confounded  in  practice,  though 
nothing,  however,  is  easier  than  to  distinguish  them  from  each  other;  for, 
in  the  former  one,  the  uterus  cannot  be  raised,  whereas,  in  the  case  of 
descent,  it  yields  without  resistance  to  the  pressure  of  the  finger,  and  resumes 
its  natural  position. 

Congenital  s)  ortening  is  a  frequent  cause  of  sterility,  as  well  as  of  sharp 


INTERNAL    ORGANS    OF    GENERATION.  69 

pains  in  coition,  and  is  a  fruitful  source  of  the  acute  or  chronic  inflam- 
matory engorgements  of  the  uterus.  I  have  met  with  a  case  of  considerable 
shortening  of  the  vagina,  in  which  the  os  tincse  had  been  sufficiently  dilated 
by  the  membrum  virile,  to  admit  the  index  finger.  In  some  instances  the 
repeated  coition  produces  a  sort  of  artificial  vagina,  behind  the  os  uteri,  at 
the  expense  of  the  posterior  vaginal  wall,  and  if  the  finger  be  then  carried 
under  the  neck  of  the  womb,  it  will  dip  into  a  pocket,  the  anterior  wall  of 
which  is  placed  against  the  posterior  one  of  the  uterus.  This  artificial 
vagina,  produced  by  forcing  up  the  posterior  cul-de-sac,  is  sometimes  longer 
than  the  natural  canal. 

The  vagina  is  in  relation  by  its  external  face :  in  front,  with  the  bas-fond 
of  the  bladder,  to  which  it  is  united  by  some  condensed  areolar  tissue,  and 
also  with  the  canal  of  the  urethra,  which  indeed  appears  to  be  channelled 
out  in  its  substance ;  behind,  it  is  connected  with  the  rectum,  superiorly  by 
a  double  fold  of  peritoneum,  and  inferiorly  by  areolar  tissue,  which  is  less 
condensed  than  that  existing  in  front.  Hence,  the  rectum  is  seldom  drawn 
upon  in  the  displacements  of  the  uterus,  whilst  the  bladder  always  partici- 
pates more  or  less  in  these  accidents.  The  lateral  borders  afford  attach- 
ment, above  to  the  broad  ligaments,  and  below  to  the  pelvic  areolar  tissue 
and  to  some  venous  plexuses. 

The  internal  face  of  the  vagina  is  covered  by  a  mucous  membrane,  con- 
tinuous with  that  of  the  uterine  cavity,  excepting  that  its  epithelium  is  not 
prolonged  into  the  orifice  of  the  latter,  but  terminates  by  a  sort  of  denti- 
culated border,  similar  to  the  relation  of  the  oesophageal  epidermis  with  the 
stomach ;  the  internal  surface  also  exhibits  some  wrinkles  or  rather  some 
transverse  elevations  near  the  vulvar  orifice.  A  raphe,  or  prominent  ridge 
found  on  the  median  line,  extends  the  whole  length  of  the  anterior  wall  of 
the  vagina,  affording  origin  to  all  those  rugae ;  but  the  raphe  is  not  so  well 
marked  on  the  posterior  parietes  as  on  the  anterior ;  the  term  columns  of  the 
vagina  has  been  applied  to  these  two  ridges. 

The  transverse  rugae  are  much  better  developed  in  young  virgins  and 
aged  females ;  but,  on  the  contrary,  during  pregnancy,  and  for  a  short  tune 
after  delivery,  they  are  nearly  effaced.  These  transverse  rugae  have  by 
some  physiologists  been  regarded  as  organs  of  special  sensation,  and  as 
designed  to  increase  friction  by  the  irregularities  which  they  present. 

[The  upper  extremity  of  the  vagina  embraces  the  neck  of  the  uterus,  to  which  it 
is  attached,  at  the  junction  of  the  lower  with  the  middle  third.  The  neck  is  thus 
divided  into  two  portions,  an  intra-vaginal  and  a  supra-vaginal  portion.  At  the 
point  of  insertion  there  is  a  true  continuity  of  tissue  between  the  vagina  and  uterus, 
inasmuc/  as  on  the  one  hand  the  vaginal  mucous  membrane  is  simply  reflected  so 
as  to  form  the  mucous  membrane  of  the  os  tincae,  whilst  on  the  other,  the  muscular 
fibres  of  the  vagina  are  directly  continuous  with  those  of  the  uterus.] 

In  thus  folding  upon  itself  in  order  to  embrace  the  neck,  the  mucous 
membrane  of  the  vagina  forms  a  circular  groove  or  cul-de-sac,  described  as 
the  anterior  and  posterior  cul-de-sac.  The  posterior  one  is,  generally,  deeper 
than  the  anterior,  owing  probably  to  the  insertion  of  the  vagina  behind, 
upon  a  more  elevated  point  of  the  neck. 


70  FEMALE  ORGANS  OF  GENERATION. 

The  inferior  extremity,  or  vulvar  orifice,  presents,  in  front,  a  transverse 
rugous  prominence,  that  seems  to  diminish  the  entrance. 

Structure  of  the  Vagina.  —  [The  walls  of  the  vagina  average  in  thickness  from 
one-eighth  to  three-sixteenths  of  an  inch.  It  is  composed  of  three  layers:  one 
external  or  cellulo-lihrous ;  a  middle  or  muscular  one;  and  the  internal  or  mucous. 

The  external  layer  is  composed  of  fibres  of  both  elastic  and  connective  tissue;  it 
blends  externally  with  the  organs  surrounding  the  vagina,  and  internally  with  the 
middle  layer. 

The  middle  layer  is  composed  of  muscular  fibres  which  are  inserted  in  front  upon 
the  branches  of  the  ischium  and  pubis,  and  are  continued  upward  to  become  blended 
with  the  middle  layer  of  fibres  of  the  uterus.  Some  again  disappear  upon  the  utero- 
sacral  ligaments,  whilst  others  cross  each  other  in  all  directions,  leaving  interspaces 
occupied  by  projecting  veins. 

The  internal  or  mucous  layer  is  of  a  pale-red  color,  which  becomes  violet  during 
menstruation  and  especially  during  pregnancy.  Its  external  surface  is  con- 
founded with  the  preceding  layer,  whilst  its  internal  is  covered  with  tessellated 
epithelium  and  abounds  in  folds  analogous  to  papillae.  For  a  long  time  this  mem- 
brane was  supposed  to  be  rich  in  mucous  follicles,  but  anatomists  now  agree  in  the 
opinion  that  the  vagina  is  destitute  of  mucous  glands. 

In  great  part,  the  walls  of  the  vagina  are  composed  of  a  tissue  possessing  all  the 
characters  of  spongy  erectile  tissue;  that  such  is  the  case  has  been  proved  beyond 
cavil  by  the  researches  of  M.  Kobelt  and  Ch.  Rouget.] 

According  to  Kobelt,  this  erectile  tissue  is  composed  of  several  superposed 
layers  of  venous  network  which  proceed  from  the  bulb,  the  finest  ramifica- 
tions extending  into  the  mucous  membrane.  This  true  spongy  body  extends 
continuously  through  the  entire  limits  of  the  vestibule  and  of  the  vagina, 
and  seems  connected  with  the  veius  of  the  parenchyma  of  the  uterus.  The 
great  vascularity  of  the  walls  of  the  vagina  explains,  to  a  certain  extent, 
the  dangers  consequent  upon  their  rupture.  Surrounding  the  lower 
extremity  of  the  vagina  are  a  few  muscular  fibres,  that  constitute  what  is 
erroneously  called  (see  below)  the  constrictor  vaginae  muscle.  In  some 
females,  this  is  quite  strong  and  well  developed. 

Finally,  under  the  name  of  bulb  of  the  vagina,  a  swelling  or  cavernous 
body  is  described,  that  separates  the  orifice  of  this  canal  from  the  roots  of 
the  clitoris:  moderately  thick  in  the  centre,  where  it  is  placed  between  the 
meat  us  urinarius  and  the  junction  of  the  cruras  clitoridis,  it  gradually  swells 
out,  as  it  recedes  from  this  point,  and  terminates  below  in  an  enlarged 
extremity  on  the  sides  of  the  vagina,  being  deficient,  however,  on  the 
posterior  wall  of  this  canal.  The  length  of  the  bulb,  when  injected,  is  about 
one  inch  and  three-eighths  of  an  inch ;  its  greatest  width,  from  one-half  to 
three-quarters  of  an  inch,  and  its  thickness  from  about  three-eighths  of  an 
inch  to  one-quarter  of  an  inch.  (Kobelt.)  The  bulb  of  the  vagina  is  com- 
posed of  an  erectile  tissue  analogous  to  that  of  the  bulb  of  the  urethra  in 
the  male,  and  communicates  freely,  as  shown  by  M.  Deville,  with  the 
cavernous  tissue  of  the  clitoris,  by  means  of  several  veins  of  considerable  size. 

The  bulb  of  the  vagina  is  surrounded,  as  it  were,  by  a  layer  of  muscular 
fibres  (constrictor  cunni),  in  regard  to  the  arrangement  of  which  authors 
differ.  According  to  Kobelt,  there  are  two  constrictor  muscles.  It  takes 
its  origin  by  a  large  and  flattened  base  from  the  aponeurosis  of  the  perineum, 
almrst  directly  at  the  middle  of  the  space  which  separates  the  anus  from 


INTERNAL   ORGANS    OF   GENERATION. 


71 


the  tuberosity  of  the  ischium  ;  thence  it  rises,  becoming  at  the  same  time 
narrower  towards  the  clitoris,  and  covers  or  rather  embraces  in  the  shape 
of  a  half  cylinder  the  entire  length  and  width  of  the  hull)  of  the  vagina. 

A  closer  examination,  says  Kobelt,  shows  that  this  muscle  is  composed 
of  two  flattened  layers,  the  deeper  of  which  glides  in  between  the  upper 
border  of  the  bulb  and  the  root  of  the  clitoris,  and  so  appears  above  the 
urethra  to  unite  with  the  muscle  of  the  opposite  side ;  the  upper  layer,  on 
the  contrary,  which  is  also  flat,  rises  upon  the  back  of  the  clitoris,  and  is 
connected  with  its  fellow  by  a  flat  and  narrow  tendon. 

This  muscle,  which  is,  in  fact,  at  a  considerable  distance  from  the  vaginal 
orifice,  has  been  erroneously  regarded  as  a  sphincter  of  the  vagina.  Now 
its  power  to  diminish  the  orifice  of  the  vagina  is  but  momentary,  and  only 
by  compressing  the  bulb  when  greatly  distended  at  the  moment  of  coition. 
Its  proper  office  is,  in  fact,  that  of  a  compressor  of  the  bulb,  whilst  its  upper 
extremity  tends,  at  the  same  time,  to  depress  the  gland  of  the  clitoris  towards 
the  vestibule. 

Vessels. — The  vaginal  arteries  come  from  the  hypogastric;  the  veins  are 
very  numerous  and  plexiform,  and  discharge  into  the  hypogastrics ;  the 
lymphatics  empty  into  the  ganglions  of  the  pelvis,  and  the  nerves  arise  from 
the  hypogastric  plexus. 

The  vagina  serves  in  the  female  both  as  the  organ  of  copulation  and  as 
the  canal  for  the  passage  of  the  menstrual  fluid,  and  for  that  of  the  product 
of  conception. 

AKTICLE  II. 

OF   THE    UTERUS. 

The  uterus  is  the  organ  of  gestation,  in  which  the  ovum  is  destined  to 
remain,  from  the  period  of  its  escape  from  the  Fallopian  tube,  until  the 
moment  of  linal  delivery. 


it   resembles   a   small 
pear    flattened    from 


In  form, 
gourd,  or  a 
before  backwards,  having  its  base 
turned  upwards  and  the  apex 
downwards. 

The  organ  is  divided  into  two 
parts,  the  superior  of  which,  called 
the  body,  is  the  Largest,  and  coin- 
prises  more  than  half  the  total 
length;  the  other,  or  inferior  por- 
tion, sty  led  the  neck,  is  smaller ;  a 
slight  circular  constriction  serves 
to  indicate  externally  the  point  of 
union  of  the  body  with  the  neck. 

The  axis  runs  from  ahove  down- 
wards, and  from  before  backwards, 
corresponding  nearly  with  that  of 
the  superior  strait. 

It   is  situated  in  the  excavation, 


Vir,    23. 


The  Internal  Genital  Organs,  (Tarnier.) 

i.  [Jteru8,  anterior  face,    o  o'.  Ovaries,     p  p'.  The 

pavilion,    a.  The  Intra-vaginal  porti< f  the  neck  "i 

the  uterus.     R  a'.  The   round    ligit tits,     n  v.  The 

-  .1   in.i  laid  open,    i  i '    Lai  ge  ligament.    M.   i 
men)  of  (lie  ovary,    t  t'.  Fallopian  tubes. 


72  FEMALE  ORGANS  OF  GENERATION. 

usually  on  the  median  line,  between  the  bladder  and  n  cturn,  being  retained 
in  position  by  the  round  and  the  broad  ligaments  on  the  sides,  and  below 
by  the  vagina,  upon  which  it  rests. 

[The  situation  of  the  uterus  is  affected  by  the  fulness  or  emptiness  of  the  bladder. 
When  the  latter  is  empty,  the  uterus  is  near  the  pubis  and  the  neck  directed  back- 
ward. When  the  bladder  is  full,  the  uterus  is  pushed  back,  and  its  axis  corresponds 
nearly  with  that  of  the  vagina.] 

As  we  have  said  before,  the  neck  of  the  uterus  is  embraced  about  its 
middle  by  the  mucous  membrane  of  the  vagina,  being  thereby  divided  into 
two  portions,  of  which  the  one  situated  above  the  insertion  of  the  vagina  is 
called  the  superior  vaginal ;  and  the  other,  which  projects  into  the  upper 
part  of  that  canal,  is  termed  the  inferior  vaginal  portion  of  the  neck. 

The  connections  of  the  uterus  are  very  loose  and  extensible ;  it  therefore 
exhibits  a  great  degree  of  mobility,  and  may  easily  be  moved  in  «very 
direction. 

Its  volume  varies  with  age,  being  quite  small  prior  to  the  fifteenth  year, 
but  augmenting  rapidly  at  this  era ;  the  womb  never  resumes  completely  its 
primitive  dimensions  in  women  who  have  borne  children,  and  finally,  in 
advanced  age,  it  often  appears  to  waste  away,  and  to  dwindle  down  to  the 
size  it  had  prior  to  the  fifteenth  year.  Its  dimensions  after  puberty  are  as 
follows,  viz. :  The  vertical  diameter  varies  from  two  and  five-eighths  to  two 
and  three-quarter  inches ;  the  transverse  one,  at  the  fundus,  one  and  three- 
eighths  to  one  and  a  half  inches.  Certain  physiological  conditions  produce 
a  great  augmentation  in  its  volume.  For  instance,  I  have  frequently 
observed  at  the  approach  of  the  monthly  courses,  that  it  presented  twice 
the  ordinary  size  at  least,  and  in  some  women  the  increase  in  volume  is  so 
marked  at  this  period  as  to  be  mistaken  for  the  commencement  of  a  preg- 
nancy.    (See  Diagnosis  of  Pregnancy.) 

The  uterus  likewise  varies  in  situation  at  different  epochs ;  thus  it  sur- 
mounts the  superior  strait  in  the  foetus,  and  rests  in  the  abdominal  cavity, 
so  that  the  Fallopian  tubes  and  ovaries  occupy  the  iliac  fossoe,  the  fundus 
uteri  corresponding  to  the  fifth  lumbar  vertebra.  After  birth,  in  conse- 
quence of  the  development  of  the  pelvis,  it  appears  to  sink  gradually  into  the 
excavation,  and,  at  ten  years,  the  fundus  is  on  a  level  with  the  superior  strait, 
but  subsequently  gets  below  this  point.  The  womb  is  generally  inclined 
to  the  right  or  left  in  aged  females,  or  is  turned  backwards  on  the  rectum. 

The  axis  of  the  uterus  approaches  that  of  the  inferior  strait  in  many 
women,  especially  in  those  having  a  short  vagina.  It  must  further  be 
observed,  that  the  direction  described  by  us  as  normal,  is  far  from  being 
constant  in  all  women  ;  thus,  in  some  cases,  the  fundus  may  be  thrown  so 
far  forwards  as  to  render  the  anterior  wall  the  most  inferior  part,  thereby 
constituting  what  pathologists  have  described  as  an  anteversion ;  in  others, 
the  superior  border  is  thrown  towards  the  most  inferior  portion  of  the 
sacrum,  the  neck  being  carried  behind  the  posterior  face  of  the  pubis,  thus 
producing  a  retroversion ;  again,  it  is  often  turned  towards  one  side  of  the 
excavation,  the  neck  being  directed  to  the  opposite  side  :  this  is  lateral  version 


INTERNAL    ORGANS    OF    GENERATION. 


73 


Another  singular  anomaly  in  the  relative  direction  of  the  axis  of  the 
body  and  that  of  the  neck  of  the  uterus  remains  to  be  described.  In  the 
normal  condition,  the  axis  of  the  neck  seems  to  be  identical  with  that  of  the 
body,  and  to  be  simply  a  continuation  of  it.  Now,  in  some  subjects,  the 
body  of  the  uterus  is  found  to  form  with  the  neck  an  angle  which  approaches 
more  or  less  to  a  right  angle,  as  though  one  of  these  parts  had  been  strongly 
bent  upon  the  other,  like  the  body  of  a  retort  upon  its  beak.  This  inflexion 
may  take  place  anteriorly,  posteriorly,  or  laterally,  and  has  been  styled 
accordingly,  anteflexion,  retroflexion,  and  lateroflexion. 

This  alteration  in  the  relation  of  the  axis  of  the  body  with  that  of  the 
neck  of  the  womb  may  occur  accidentally,  and  we  have  several  times 
observed  it  as  a  consequence  of  anteversion  or  retroversion,  but  certainly  it 
is  often  congenital,  and  then,  should  it  remain  after  puberty,  and  especially 
should  it  increase  in  extent,  it  might  become  a  cause  of  sterility. 

The  relative  height  of  the  fundus  and  neck 
of  the  uterus,  the  plane  of  the  os,  and  the  axis 
of  the  body  are  indicated   in  Fig.  23a,  in 
which  the  bladder,  B,  and  the  rectum,  C,  are 
represented  as   moderately  distended.     As 
said  before,  the  situation  of  the  uteri 
subject  to  continual  change,  being 
effected  by  fulness  or  emptiness  of 
the    bladder.     When   the   bladder 
is    empty,    the   abdominal   viscera 
press  upon  the  fundus  of  the  womb 
and  bend  it  forward.     This  inflec- 
tion is  regarded  by  many  as   per- 
manent and  inherent  to  the  uterus 
itself. 

The  weight  of  the  womb,  in  girls  at  puberty,  is  from  six  to  ten  drachms ; 
but  in  women  who  have  had  children,  it  ranges  from  an  ounce  and  a  half 
to  two  ounces ;  and  from  one  to  two  drachms  in  very  aged  females. 

The  uterus  exhibits  an  external  and  an  internal  surface. 

§  1.  External  Surface. 

In  the  study  of  the  external  surface  we  should  recognize  the  division  into 
the  body  and  the  neck. 

Of  the  Body  of  the  Uterus.  —  The  external  surface  presents  for  our 
study  two  faces,  two  borders,  a  base,  and  an  apex. 

The  anterior  face  of  the  body  is  slightly  convex,  is  covered  by  the  peri- 
toneum on  its  superior  three-fourths,  and  lies  in  a  mediate  relation  with  the 
posterior  face  of  the  bladder,  from  which  it  is  frequently  separated  by  some 
folds  of  the  small  intestine;  whilst,  at  the  inferior  fourth,  it  is  in  contact 
with  the  bas-fond  of  the  bladder,  to  which  it  is  united  by  some  loose  cellular 
tissue.  This  latter  connection  explains  the  frequent  participation  of  the 
bladder  in  the  uterine  displacements,  however  inconsiderable  they  may  be, 
as  also  how  in  certain  cases  vesico-uterine  fistulas  may  be  produced  after 
difficult  labors. 


FIG.  23a. 


Diagram,   showing  relative    position  ol 
pelvic  viscera (Farre). 


74  FEMALE  ORGANS  OF  GENERATION. 

The  posterior  face  is  much  more  convex  than  the  preceding,  heing 
covered  throughout  its  whole  extent  by  the  peritoneum  ;  it  is  in  a  mediate 
relation  with  the  anterior  surface  of  the  rectum,  the  intestinal  convolutions. 
however,  often  separating  them ;  it  maybe  readily  examined  through  the 
rectum.  The  lateral  borders  are  slightly  concave,  affording  an  attachment 
to  the  broad  and  the  round  ligaments  ;  but,  as  M.  Cruveilhier  remarks 
these  ligaments  are  attached  to  the  anterior  edge  of  the  borders,  and  hence 
all  the  thickness  of  these  margins  is  found  behind  the  broad  ligaments,  and 
consequently  the  latter  are  on  the  same  plane  as  the  anterior  face  of  the 
womb. 

The  base,  fundus,  or  superior  border  of  the  womb  is  convex,  looking  upwards 
and  forwards,  and  covered  by  the  convolutions  of  the  small  intestine.  It  never 
attains  the  level  of  the  superior  strait  in  the  unimpregnated  state,  and  there- 
fore it  is  only  possible  to  feel  it  through  the  inferior  abdominal  wall,  by  using 
great  pressure. 

At  the  junction  of  this  base  with  the  lateral  borders  of  the  body  the  two 
angles  are  formed,  from  which  the  Fallopian  tubes  and  ligaments  of  the 
ovary  arise. 

The  apex  or  inferior  angle  is  continuous  with  the  neck,  which  next  claims 
our  attention. 

Of  the  Neck  of  the  Uterus. — Very  remarkable  differences  are  found 
between  the  neck  of  the  uterus  in  a  woman  who  has  borne  children,  and 
that  in  one  who  has  never  been  a  mother ;  we  shall,  therefore,  consider  it 
successively  in  each,  because  the  modifications  it  undergoes  during  pregnancy 
can  only  be  appreciated  after  a  careful  study  of  the  ordinary  condition. 

1st.  In  the  woman  who  has  never  been  a  mother,  the  neck  of  the  uterus  is 
from  an  inch  to  an  inch  and  three-eighths  in  length,  and  is  separated  from 
the  body  by  a  narrow,  constricted  portion,  which  can  easily  be  distinguished, 
even  on  the  exterior  of  the  organ.  At  the  central  part,  where  it  is  a  little 
enlarged  and  fusiform,  it  is  about  three-quarters  of  an  inch  in  the  transverse 
diameter,  and  half  an  inch  in  the  antero-posterior  one.  Near  the  junction 
of  the  superior  third  with  the  inferior  two-thirds,  it  is  embraced  by  the 
upper  end  of  the  vagina,  which  descends  a  little  loAver  on  the  anterior  than 
on  the  posterior  face,  whence  the  subvaginal  portion  of  the  neck  is  some- 
what longer  behind;  but  the  contrary  is  true  for  that  part  above  the  vagina. 

The  cervix  is  terminated  by  an  extremity  that  is  less  voluminous  than 
the  other  portions  of  its  extent,  so  as  to  present  a  conical  form  to  the  finger. 
This  extremity  bears  the  name  of  the  os  tincoz,  or  tench's  mouth.  The  os 
tincoe  presents  two  lips,  separated  by  a  small  transverse  fissure,  somewhat 
swollen  in  the  middle,  called  the  external  orifice  of  the  neck.  The  orifice 
is  sometimes  difficult  to  find  in  a  young  marriageable  girl.  But,  according 
to  Dubois,  if  the  index  encounters  it,  we  may  recognize  the  part  by  compar- 
ing the  sensation  then  experienced  with  that  produced  by  applying  the  pulp 
of  the  finger  upon  the  extremity  of  the  nose,  and  feeling  the  depression  be- 
tween the  aloe  nasi.  The  anterior  lip  is  the  thicker,  though  both  are  very 
nearly  of  the  same  length,  the  anterior  one,  perhaps,  descending  a  little 
lower  than  the  other.     Most  authors  teach  that  the  anterior  lip  of  the  neck 


INTERNAL     ORGANS     OF     GENERATION.  75 

descends  lower  than  the  posterior.  In  detaching  the  uterus  from  a  dead 
body,  no  great  difference,  however,  is  observed  in  this  respect,  but,  on  the 
contrary,  if  we  touch  a  female,  the  distinction  is  much  better  marked.  I 
believe  this  results  solely  from  the  fact  of  the  neck  being  directed  a  little 
posteriorly,  so  that  the  surface  of  the  os  tincse  is  not  horizontal,  but  inclined 
backwards ;  and,  therefore,  the  anterior  lip  is  necessarily  somewhat  lower 
than  the  posterior.  Besides,  the  finger  in  passing  from  below  upwards,  and 
from  before  backwards,  must  first  encounter  the  anterior  lip,  and  is  then 
obliged  to  go  higher  and  further  behind  to  reach  the  posterior  one.  These 
lips  are  smooth  and  polished  throughout,  neither  presenting  any  inequali- 
ties nor  any  depressions  ;  in  fact,  the  whole  external  surface  of  the  neck  is 
equally  smooth,  and  without  elevations. 

The  cervix,  as  already  stated,  is  slightly  directed  *ro.  23<*. 

backwards,  so  that,  if  prolonged,  it  would  terminate 
near  the  coccyx,  or  the  most  interior  part  of  the  sa- 
crum. It  is  situated  in  the  upper  half  of  the  excava- 
tion, yet  the  finger  can  easily  reach  and  pass  over  its 
whole  exterior  surface. 

2d.  In  the  female  who  has  had  several  children,  the 
neck  has  not  the  same  aspect,  and  the  length  is  so  varia- 
ble that  it  is  not  possible  to  announce  it  in  advance ; 
though  we  may  say,  in  general  terms,  that  it  is  shorter 

°-  ■  i        -i  n  Differences  in  the  uterine  necfc 

in  proportion  to  the  larger  number  of  children  the       and  its  external  orifice, 
woman  has  borne,  a  portion  of  it  seeming,  as  it  were,  to      « et  c,  of  the  nuiiiparous. 
have  been  destroyed  at  every  labor.     Two  females,      b  et  &> of  the  ™UiPar0US- 
one  of  whom  had  seventeen,  theother  nineteen  children,  have  been  under  my 
care;  the  neck  in  each  was  completely  destroyed  in  its  intra- vaginal  portion. 

This  diminished  length  of  the  intra-vaginal  portion  of  the  neck  in  women 
who  have  borne  many  children,  is  due  to  the  strong  traction  upon  the  upper 
extremity  of  the  vagina  in  the  preceding  pregnancies,  produced  by  the  ele- 
vation of  the  uterus ;  in  consequence  of  this  traction,  and  the  laxity  of  its 
adhesions  with  the  middle  part  of  the  neck,  the  vagina  becomes  detached 
from  it  at  that  point,  and  adheres  to  it  only  at  its  inferior  extremity.  When 
this  has  occurred,  it  is  plain  that  the  portion  which  projects  into  the  vagina 
must  be  much  less  considerable  than  before.  Although  it  still  preserves  a 
certain  length,  the  regular  form  that  it  previously  had  is  wanting,  for  it  is 
no  longer  a  fusiform  body,  with  an  exterior  surface  polished  and  smooth 
everywhere,  but  a  kind  of  irregular  teat,  covered  on  its  external  face  by 
more  or  less  numerous  elevations. 

Sometimes  it  is  more  swollen  at  the  inferior  portion,  whilst  the  upper 
part  appears  to  be  hollowed  out  in  its  wdiole  circumference  by  a  deep  exca- 
vation. 

The  orifice  of  the  os  tincie  is  sufficiently  patulous  to  admit  the  extremity 
of  the  finger,  or  even  one-half  of  its  ungual  portion  may  occasionally  be 
introduced.  The  lips  are  unequal,  presenting  a  variable  number  of  notches 
Being  rarely  found  on  the  middle  part  of  the  lips,  these  depressions  are  con- 
tinually met  with  about  the  level  of  the  commissures,  and  more  frequently 


76 


FEMALE  ORGANS  OF  GENERATION. 


on  the  left  side  than  the  right.  They  result  from  the  lacerations  that  have 
occurred  in  former  labors,  at  the  moment  when  the  head  cleared  the  oa 
uteri ;  and  the  lochial  discharges  have  prevented  the  lips  of  these  little 
wounds  from  uniting,  and  they  have  cicatrized  separately.  The  depression? 
are  sometimes  so  numerous  as  to  subdivide  the  lips  into  six  or  eight  small 
tubercles,  separated  by  as  many  fissures  of  variable  depth. 

In  case  the  woman  has  not  had  children  for  several  years,  and  more  espe- 
cially if  she  has  had  but  one  or  two  of  them,  these  characters  are  much  less 
determined,  the  orifice  is  nearly  obliterated,  and  the  neck  has  gradually 
resumed  its  primitive  form  ;  nevertheless,  the  fissure  of  the  orifice  is  always 
sufficiently  marked,  as  well  as  the  inequalities  on  the  lips,  to  indicate  ante- 
cedent labors.  These  marks  may  become  more  and  more  faint,  but  they 
never  disappear  altogether. 

The  frequency  of  these  depressions  on  the  left  side  may  be,  I  think, 
readily  explained.  When  the  head  passes  through  the  neck,  it  is  evident 
that,  if  a  laceration  be  produced,  it  will  be  at  the  point  which  sustains  the 
greatest  strain.  Now,  the  left  occipito-iliac  positions  being  much  the  more 
frequent,  the  occiput,  which  constitutes  the  largest  extremity  of  the  head, 
will  consequently  correspond  to  the  left  commissure  of  the  neck.  Further, 
the  uterus  is  habitually  inclined  to  the  right,  so  that  the  line  of  its  con- 
tractions is  directed  from  right  to  left,  and,  therefore,  acts  more  energetically 
on  the  left  side  of  the  cervix.  Hence  the  greatest  strains  occur  at  this 
point. 

§  2.  Internal  Surface. 

[The  uterus  has  an  internal  surface  which  defines  its  cavity.  This  cavity  lias, 
in  the  virgin  condition,  a  longitudinal  extent  of  about  two  and  a  quarter  inches, 
and  of  two  and  a  half  inches  after  several  labors.  We  may  distinguish  the  cavity 
of  the  body  and  the  cavity  of  the  neck.  The  length  of  the  former  is,  in  virgins, 
rather  less  than  that  of  the  neck,  whilst  in  multiparas  the  two  dimensions  are 
nearly  equal;  —  that  of  the  body  being,  perhaps,  rather  greater  than  that  of 
the  neck. 

a  The  cavity  of  the  body  is  triangular  in  shape,  having  two  faces,  three  edges, 
itnd  Miree  angles.  The  two  faces  are  plane,  and  separated  only  by  a  thin  layer 
jf  mucus,  so  that  they  may  be  said  to  be  in  contact. 


Cavity  of  the  Uterus  and  the  Fallopian  Tubes. 
a.  Superior  border  or  fundus  of  the  womb.    b.  Cavity  of  the  womb.    o.  Cavity  of  the  neck  of  the  uterus. 
D.  The  canal  of  the  Fallopian  tube  cut  open.    e.  The  fimbriated  extremity  or  pavilion,  likewise  laid  open. 

pp.  The  ovaries,  one-half  of  which  has  I n  removed  son-  to  bring  into  view  several  ol  the  Graafian 

-.    q.  The  cavity  of  the  vagina,    h  ii.  The  ligaments  of  the  ovaries,    g  g.  The  round  ligament. 


INTERNAL   OBGANS   OF    GENERATION. 


77 


Of  the  three  edges,  the  upper  extends  from  the  orifice  of  one  Fallopian  tube  to 
the  other,  and  the  two  lateral  ones,  from  the  orifice  of  each  tube  to  the  upper  or 
internal  orifice  of  the  neck.  In  virgins,  the  three  edges  are  curvilinear,  with  con- 
vexity directed  inward;  in  multipara,  they  are  either  rectilinear,  or  present  a 
slight  curvature  with  concavity  directed  internally. 

The  three  angles  are  described  as  the  superior  or  lateral,  and  the  inferior.  The 
two  superior  angles  are  at  the  extremities  of  the  upper  edge  where  it  joins  the 
lateral  edges,  and  where  are  situated  the  very  minute  orifices  of  the  Fallopian 
tubes.  The  inferior  angle,  formed  by  the  convergence  of  the  two  lateral  edges, 
also  presents  an  opening  in  the  internal  orifice  of  the  neck,  by  which  the  cavity 
of  the  body  communicates  with  that  of  the  neck.] 

In  the  state  of  vacuity,  no  cavity,  to  speak  correctly,  exists  in  the  womb, 
for   the  uterine  walls  are  in  contact  throughout  their  extent ;  the  cavity 

Fig.  25. 


Virgin  uterus,     a.  Anterior  view;  b.  Median  section;  c.  Lateral  section.     (Sappey.) 


like  that  of  the  pleura  for  example,  has  a  real  existence  only  when  the 
walls  hecome  separated  by  a  liquid  effusion. 

The  congenital  deficiency  of  a  cavity  in  the  body  is  very  rare,  but  yet  no 
trace  of  it  existed  in  a  uterus  presented  to  M.  Cruveilhier  by  M.  Etostan, 
although  that  of  the  neck  remained.  In  aged  women,  however,  it  is  not 
very  rare  to  find  the  cavity  partly  effaced  by  more  or  less  extensive  adhesions. 

B.  The  cavity  of  the  neck  is  fusiform,  flattened  from  before  backwards,  and 
presents  an  assemblage  of  rugte  on  its  anterior  and  posterior  Avails,  winch 
constitute  a  median  vertical  column  upon  each  wall,  occupying  the  whole 
length  of  the  neck,  and  from  which  a  number  of  smaller  columns  pass  off 
at  various  angles,  representing  a  fern  in  relief.  The  term  arbor  vita  has 
been  applied  to  these  rugosities.  After  delivery  they  frequently  disappear, 
but  sometimes  they  still  persist. 

The  uterine  cavity  likewise  exhibits  a  variable  number  of  transparent 
vesicles,  mistaken  by  Naboth    for  eggs,  hence  they  have  been  called   the 


78  FEMALE   ORGANS   OF   GENERATION, 

ovuia  Nabothi.  These  vesicles  are  nothing  more  than  simple  muciparous 
follicles,  and  they  are  particularly  abundant  in  the  neighborhood  of  the 
neck.  They  secrete  a  gelatinous  mucus,  which  may  accumulate  in  the 
cavity  of  the  neck,  and  so  obstruct  it  as  to  render  fecundation  impossible. 

The  internal  surface  of  the  uterus  is  much  more  vascular  in  the  body 
than  in  the  neck.  This  difference  is  particularly  well  marked  in  women 
who  have  died  during  the  menstrual  period.  The  cavity  of  the  body  is  of 
a  rose  color,  and  that  of  the  neck  of  a  pearly  gray  hue,  which  is  probably 
due  to  the  slight  vascularity  of  this  part  in  comparison  with  that  of  the 
lining  membrane  of  the  body. 

§  3.  Structure  of  the  Uterus. 

In  the  ordinary  condition  of  the  womb,  this  structure  is  difficult  to 
make  out,  but  it  becomes  much  more  evident  during  the  period  of  gestation. 

The  constituent  parts  of  the  organ  are :  a  middle  or  tissue  proper,  an 
external  peritoneal  membrane,  and  an  internal  mucous  one,  together  with 
numerous  vessels  and  nerves. 

a.  Tissue  Proper. — This  tissue  is  of  a  grayish  color,  and  is  very  dense 
in  structure,  creaking  like  cartilage  under  the  scalpel.  In  general,  the 
neck  appears  less  firm  in  consistence  than  the  body,  resulting,  as  M.  Cru- 
veilhier  supposes,  from  the  former  being  the  more  frequent  seat  of  san- 
guineous fluxions.  It  sometimes  happens,  as  after  a  suppression  of  the 
menses,  or  just  before  or  after  menstruation,  that  the  uterus  has  a  more 
decided  red  color  and  its  tissue  is  more  supple.     (See  Menstruation.*) 

The  proper  tissue  of  the  womb  is  composed  of  fibres  disposed  lengthwise. 
The  nature  of  these  fibres  has  led  to  numerous  discussions,  but  at  the 
present  day  they  are  proven  by  the  microscope  to  be  muscular,  and  since 
this  muscular  nature  becomes  clearly  evident  towards  the  end  of  gestation 
(see  Pregnancy),  we  must  acknowledge  that,  notwithstanding  the  fibrous 
appearance  of  its  tissue  in  the  unimpregnated  condition,  the  fibres  composing 
it  are  not  the  less  muscular  in  their  structure.  This  organization  is  con- 
cealed by  the  state  of  condensation ;  of  atrophy,  maintained  either  by 
inertia  or  want  of  action  ;  but  which  becomes  distinct,  in  consequence  of  the 
very  considerable  determination  to  the  uterus,  of  its  distention,  and  of  the 
development  of  its  fibres  during  pregnancy. 

According  to  most  anatomists,  the  direction  of  these  fibres  in  the  state  of 
vacuity  is  very  irregular,  and  their  inter-crossing  is  nearly  inextricable, 
as  every  one  must  confess,  in  this  particular  condition,  says  M.  Cruveilhier. 
But  as  the  structure  of  the  uterus,  except  in  gestation,  is  not  of  any  conse- 
quence (practically  speaking)  to  the  accoucheur,  we  refer  to  the  article 
Pregnancy  for  the  more  particular  study  thereof. 

B.  The  External  or  Peritoneal  Membrane. — The  peritoneum  having 
covered  the  posterior  face  of  the  bladder,  is  reflected  upon  the  anterior  one 
of  the  uterus,  covering  only  its  superior  three-fourths  ;  and  having  reached 
the  fundus  uttri,  and  gained  the  posterior  wall,  it  ".overs  this  entirely,  ia 
prolonged  on  the  vagina  for  a  short  distance,  and  is  then  reflected  upon  the 


INTERNAL    ORGANS    OF    GENERATION.  79 

rectum.  The  broad  ligaments  are  produced  by  the  transverse  elongations 
of  this  membrane;  and  its  falciform  folds,  seen  in  the  interval  that  separates 
the  bladder  from  the  uterus,  are  called  the  vesico-uterine,  or  the  anterior 
ligaments;  and  those  formed  by  it,  between  the  rectum  and  uterus,  are 
called  the  posterior,  or  the  recto-uterine  ligaments.  The  adherence  of  the 
peritoneum  is  quite  loose  on  the  borders  of  the  uterus,  but  it  becomes  more 
intimate  towards  the  median  line. 

c.  The  Internal  or  Mucous  Membrane. — The  existence  of  this  membrane 
was  for  a  long  time  contested,  and  there  can  be  no  doubt,  that  if  a  mem- 
brane resembling  the  majority  of  those  which  line  all  the  mucous  cavities 
be  sought  for  in  the  uterus,  it  will  be  sought  in  vain.  Still  its  existence 
is  rendered  very  probable  by  the  functions  of  the  organ,  for,  as  Cruveilhier 
has  remarked :  1st.  Every  organic  cavity  communicating  with  the  exterior 
is  lined  by  a  mucous  membrane.  2d.  Anatomy  demonstrates  that  the 
vaginal  mucous  membrane  is  continued  into  the  cavity  of  the  neck,  and 
then  into  that  of  the  uterus.  3d.  When  examined  by  a  lens,  the  internal 
surface  of  the  uterus  exhibits  a  papillary  disposition,  but  the  papilla?  are 
imperfectly  developed.  4th.  This  internal  surface  has  follicles  or  crypts 
scattered  over  it,  from  which  mucus  can  be  squeezed  out,  and  which,  if  their 
orifices  be  obstructed  or  obliterated,  become  distended  by  the  liquid,  and 
form  little  vesicles.  5th.  It  is  continually  lubricated  by  mucus.  6th,  and 
lastly ;  the  internal  surface  of  the  uterus,  like  all  other  mucous  membranes, 
is  subject  to  spontaneous  hemorrhages,  to  catarrhal  secretions,  and  to  the 
mucous,  fibrous,  and  vesicular  vegetations  called  polypi;  and  it  is  generally 
admitted  that,  wherever  there  is  an  identity  of  action,  there  is  also  an  iden- 
tity of  nature. 

These  physiological  probabilities  are  at  present  fully  confirmed  by  ana- 
tomical research,  the  numerous  preparations  in  the  possession  of  M.  Coste 
leaving  no  doubt  whatever  as  to  the  existence  of  the  mucous  membrane. 
I  shall  therefore  borrow  from  this  able  physiologist  the  principal  facts 
which  pertain  to  its  description. 

The  thickness  of  the  uterine  mucous  membrane  varies  in  different  parts 
of  its  extent.  Towards  the  middle  of  the  body,  it  forms  one-fourth  of  the 
thickness  of  the  walls  of  the  uterus ;  that  is  to  say,  its  usual  depth  at  this 
point  is  from  one-eighth  to  three-sixteenths  of  an  inch,  amounting  to  about 
the  one-fourth  of  the  thickness  of  the  uterine  parietes.  It  thins  oft"  rapidly 
towards  the  point  of  union  of  the  body  with  the  neck,  as  also  towards  the 
apertures  of  the  Fallopian  tubes.  Its  greatest  thickness  in  the  neck  does 
not  exceed  the  one  twenty-fourth  part  of  an  inch. 

The  thickness  of  the  mucous  membrane  is  clearly  exhibited  by  the  assist- 
ance of  a  perpendicular  section  of  the  uterus.  It  is  then  found  to  be  in- 
jected, and  varying  in  color  from  a  deep  or  bright  red  to  a  semi-transparent 
reddish  or  pearly  gray :  the  muscular  tissue,  on  the  contrary,  is  almost 
always  of  a  reddish-gra  'olor,  and  is  besides  easily  distinguished  by  the 
numerous  vascular  openings  upon  the  surface  of  the  section,  and  from  which 
blood  may  be  caused  to  exude  by  pressure.     In  addition,  there  is  always  a 


80 


FEMALE  ORGANS  OF  GENERATION. 


whitish  line  of  demarcation  between  the  two  tissues,  which  becomes  most 
distinct  when  the  injection  of  the  mucous  membrane  is  greatest. 

Its  consistence  is  less  than  that  of  the  tissue  proper  of  the  uterus,  being 
very  friable,  and  easily  crushed. 

It  adheres  very  strongly  to  the 
Fl0-26  substance   of   the   uterus,   and   is 

separated  from  it  with  great  diffi- 
culty :  it  is  also  incapable  of  any 
gliding  motion  upon  the  parts 
which  it  covers,  on  account  of  the 
entire  absence  of  a  sub-mucous  cel- 
lular tissue. 

Its  internal  surface  presents  a 
multitude  of  small  orifices,  rather 
regularly  arranged,  -which,  though 
barely  perceptible  to  the  naked  eye, 
become  very  evident  with  the  as- 
sistance of  a  lens.  About  forty- 
five  of  them  are  contained  in  a  space 
equivalent  to  the  square  of  one- 
eighth  of  an  inch.  They  are  the 
orifices  of  glands. 

M.  Kobin  has  given  an  excellent 
description  of  the  elements  which 
enter  into  the  composition  of  the 
mucous  membrane  ;  they  are  : 

1.  Embryo-plastic  nuclei;  2.  Ele- 
ments of  laminated  tissue ;  3.  Spe- 
cial cells,  in  very  small   amount 
except  during  pregnancy ;  4.  Amor- 
phous connective  matter ;  5.  Glands ;  6.  Capillary  vessels ;  7.  Epithelium, 
at  first  prismatic  but  becoming  pavimentous  during  pregnancy.     A  few 
words  in  regard  to  the  uterine  glands. 

Two  species  of  glands  exist  in  this  mucous  membrane,  one  being  found 
only  within  the  body  of  the  uterus,  whilst  the  other  is  confined  to  the  neck. 
1.  According  to  M.  Coste,  who  was  the  first  to  describe  them,  the  glands 
of  the  body  are  especially  visible  when  death  has  occurred  during  menstrua- 
tion ;  they  then  appear  as  minute  canals  of  about  the  one  two-hundred-and- 
fiftieth  part  of  an  inch  in  diameter,  placed  vertically  beside  each  other. 
Thev  are,  however,  disposed  so  compactly,  that  the  mucous  membrane  as  seen 
by  a  lens  appears  to  be  formed  of  them  almost  exclusively.  Their  adherent 
extremities  terminate  in  culs-de-sac  and  repose  upon  the  muscular  tissue. 
The  bodies  of  the  glands  are  rendered  somewhat  flexuous  by  the  mucous 
membrane  being  too  thin,  as  it  were,  in  the  state  of  vacuity,  for  the  length 
of  the  tubes.  They  contain  a  whitish,  viscid  fluid,  which  may  be  squeezed 
from  them,  especially  at  the  menstrual  period. 


This  figure  represents  the  arrangement  of  the  mucous 
ir.ambrane  and  of  the  tissue  proper  of  the  uterus,  as  also 
their  relative  dimensions. 

a.  Cavity  of  the  neck  and  arbor  vitae.  b.  Cavity  of 
the  body.  c.  Mucous  membrane.  D.  Intervening  mem- 
brane, e.  Represents  the  marked  thinning  off  of  the 
mucous  membrane  towards  the  neck. 


INTERNAL    ORGANS    OF    GENERATION.  81 

2.  The  glands  of  the  neck  (glands,  or  ovula  of  Naboth)  are  found  in  all 
the  interval  between  the  line  separating  the  cavity  of  the  neck  from  that  of 
the  body,  and  the  neighborhood  of  the  borders  of  the  os  tincse.  Their 
orifices  are  readily  seen  upon,  and  especially  between,  the  folds  of  the  arbor 
vita?. 

These  glands  have  the  form  of  a  minute  cylinder,  terminating  in  a  rounded 
cul-de-sac,  which  is  inflated  into  the  form  of  a  lentil  or  vial,  and  inclosed  in 
the  tissue  of  the  mucous  membrane,  even  descending  a  little  between  the 
fibres  of  the  muscular  structure. 

The  excretory  orifice  is  always  smaller  than  the  glandular  tube.  Pres- 
sure causes  the  escape  from  it  of  a  transparent,  viscid,  tenacious,  and  com- 
pletely homogeneous  fluid. 

We  shall  treat  hereafter  of  the  modifications  which  these  glands  undergo 
during  gestation. 

[The  epithelium  of  the  uterine  mucous  membrane  is  cylindric,  with  vibratile  cilia 
moving  from  without  inward.  It  is  therefore  impossible  that  the  ciliary  motion 
should  carry  the  spermatic  fluid  toward  the  openings  of  the  tubes,  as  has  been 
erroneously  supposed. 

The  entire  cavity  of  the  body  and  of  the  neck,  to  a  point  near  the  external  ori- 
fice of  the  latter,  is  covered  with  vibratile  epithelium.  Below  this  point  the  mucous 
membrane  of  the  neck  is  ^urnished  with  the  pavimentous  variety. 

D.  Vessels. — The  arteries  of  the  uterus  proceed  from  the  hypogastric  and  ovarian 
arteries.  Both  present  many  flexuosities  in  their  course  through  the  tissue  of  the 
organ,  and  are  remarkable  for  their  corkscrew  form,  recalling  the  arrangement  of 
the  helicine  arteries.     The  neck  is  less  vascular  than  the  body. 

The  veins  are  highly  developed,  anastomosing  freely,  and  forming  cavities,  as  it 
were,  in  the  muscular  tissue.  They  are  called  uterine  sinuses,  and  communicate 
largely  with  the  venous  plexuses  within  the  folds  of  the  broad  ligaments.  From 
the  latter  proceed  the  uterine  and  ovarian  veins  which  empty  into  the  correspond- 
ing trunks. 

From  the  arrangement  of  the  uterine  arteries  and  veins,  surrounded  as  they  are 
everywhere  by  muscular  partitions,  it  results,  that  the  uterus  is  a  true  erectile  organ, 
as  has  been  placed  beyond  doubt  by  an  excellent  memoir  published  by  Professor 
Rouget.  This  skilful  anatomist  has,  in  fact,  shown  that  by  injecting  the  veins  of 
the  uterus  the  organ  is  put  in  a  state  of  true  erection,  whereby  it  rises,  swells,  and 
moves  up  toward  the  abdomen.  Under  these  circumstances  its  volume  is  greater 
by  one-half  than  in  the  empty  condition,  and  the  Avails  of  the  cavity  separate  from 
each  other.  These  phenomena  doubtless  take  place  during  coition,  and  probably 
facilitate  the  ascent  of  the  spermatic  fluid. 

The  lymphatic  vessels  are  very  abundant,  and  pass  into  the  pelvic  and  lumbar 
ganglia. 

e.  Nerves. — The  nerves  are  derived  from  the  great  sympathetic,  some  of  them,  pro- 
ceeding from  the  renal  and  others  from  the  hypogastric  plexuses ;  to  the  latter  are 
united  some  fibres  from  the  sacral  plexus.] 

It  is  an  important  practical  remark  of  M.  Jobcrt,  that  the  entire  intra- 
vaginal  portion  of  the  neck  is  destitute  of  a  supply  of  nervous  fibres,  whilst 
the  portion  above  the  insertion  of  the  vagina  receives  a  great  number  of 
them,  which    form   species  of  plexuses,  furnishing   ascending   or  uterine 


82  FEMALE  ORGANS  OF  GENERATION. 

branches  and  descending  or  vaginal  ones.  The  latter  are  extremely  numer- 
ous, and  ramify  to  infinity  in  the  substance  of  the  vagina. 

This  distribution,  which  would  explain  a  number  of  physiological  and 
pathological  facts,  needs  confirmation  from  new  researches,  for  recent  prepa- 
rations deposited  by  M.  Boulard  in  the  museum  of  the  School  of  Medicine, 
give  it  a  formal  denial. 

Development.  —  According  to  some  authors,  the  uterus  is  bifid  in  the  em- 
bryo as  late  as  the  end  of  the  third  month,  but  M.  Cruveilhier  says  he  has 
never  observed  this  bifurcation.  During  the  intra-uterine  life,  the  volume 
of  the  neck  surpasses  that  of  the  body,  and  at  this  period  its  largest  por- 
tion corresponds  to  the  vaginal  extremity.  After  birth  it  remains  nearly 
stationary  until  puberty,  and  then  it  acquires  in  a  very  short  time  the 
dimensions  observed  in  the  adult  woman.  The  organ  often  becomes  atro- 
phied in  old  age. 

§  4.  Ligaments  of  the  Uterus. 

We  have  already  spoken  of  the  anterior  and  posterior  ligaments.  The 
broad  and  round  ones  still  remain  to  be  described. 

The  Broad  Ligaments. — As  elsewhere  stated,  the  double  lamina  of  the 
peritoneum,  which  covers  the  anterior  and  posterior  faces  of  the  uterus,  is 
prolonged  transversely,  the  two  folds  resting  against  each  other,  and  form- 
ing by  their  union  a  transverse  partition,  extending  from  each  side  of  the 
uterus,  which  divides  the  pelvis  into  two  cavities ;  the  anterior  of  which 
lodges  the  bladder,  and  the  posterior  the  rectum.  Outwardly,  and  below, 
these  ligaments  are  continuous  with  the  peritoneum  that  lines  the  excava- 
tion ;  their  superior  border  is  free,  and  is  extended  from  the  angles  of  the 
uterus  to  the  iliac  fossae  —  presenting  three  folds,  called  the  wings.  The 
anterior  wing  is  not  admitted  by  some  anatomists  ;  it  is  but  slightly  devel- 
oped, and  is  occupied  by  the  round  ligament.  The  middle  one  incloses  the 
Fallopian  tube,  and  the  posterior  contains  the  ovary  and  its  ligament. 

[Between  the  two  layers  of  serous  membrane,  whose  apposition  forms  the  broad 
ligament,  are  found  two  muscular  layers,  discovered  and  described  by  M.  Rouget, 
who  represents  them  as  formed  of  muscular  fibres  making  by  their  interlacement 
a  network  in  a  transverse  direction.  The  anterior  of  these  two  layers  is  continuous 
with  the  superficial  muscular  fibres  of  the  anterior  surface  of  the  uterus,  and  is 
directed  outward  so  as  to  form  a  part  of  the  round  ligament.  The  posterior  mus- 
cular layer  is  continuous  with  the  superficial  fibres  of  the  posterior  surface  of  the 
uterus,  and  is  so  directed  outwardly  as  to  become  attached  for  the  most  part  to  the 
sacro-iliac  symphysis.] 

The  two  serous  folds  that  constitute  the  broad  ligament,  are  separated  by 
a  loose  and  very  extensible  lamellated  cellular  tissue,  continuous  with  the 
fascia  propria  of  the  pelvis.  The  broad  ligaments  disappear  during  gesta- 
tion, their  two  laminae  assisting  to  cover  the  anterior  and  posterior  faces  of 
the  developed  womb. 

Bodirs  <,f  Roxenmuller,  Parovarium. — By  the  inspection  of  pieces  prepared 
by  M.  Follin,  we  have  become  assured  of  the  existence  of  an  organ  be- 
tween the  two  laminse  of  the  broad  ligament,  which  hasnot  been  even  noticed 


INTERNAL   ORGANS    OF    GENERATION. 


83 


Fio.  27. 


Bullies  of  Rusenmiiller. 

A.  Ovary. 

B.  Fallopian  tube. 

C.  Fimbriated  extremity  of  Fallopian  tube. 

D.  Culs-de-sac  of  the  tubes. 

E.  Canaliculi  proceeding  to  the  ovary. 

F.  Point  to  which  the  tubes  converge. 

G.  Vesicle  appended  to  the  Fallopian  tube. 


by  French  anatomists,  but  which  certain  German  anatomists  figure  under 
the  name  of  the  organ  of  RosenmyMer,  who  was  the  first  to  discover  it. 
Its  general  arrangement  is  not  yet  well  understood,  its  development  is 
involved  in  obscurity,  and  the  details  of  its  histology  had  not  hitherto 
been  described.     It  is  at  present  known  as  the  Parovarium. 

The  organ  is  composed  of 
seven  or  eight  tubes  folded 
upon  themselves,  terminating 
in  blind  extremities,  and  all 
converging  towards  the  tube 
which  serves  as  a  point  of  en- 
trance for  the  vessels  of  the 
ovary.  The  tubes  are  gener- 
ally closely  approximated  to 
each  other,  so  that  their  in- 
flexions frequently  correspond. 
When  examined  by  trans- 
mitted light,  the  assemblage 
of  canals  is  distinctly  seen  in 
the  broad  ligament  near  the 
fimbriated  extremity  of  the 
Fallopian  tube.  Sometimes 
these  tubes  are  not  very  appar- 
ent, and  their  number  is  much  less,  yet  some  are  always  to  be  found.  They 
exist  at  all  ages,  but  are  much  more  readily  distinguished  in  the  broad  liga- 
ments of  the  foetus,  of  of  children,  for  then  the  slight  development  of  the 
blood-vessels  does  not  obscure  them,  nor  are  they  hidden  from  observation 
by  the  fat,  which  infiltrates  the  laminre  of  the  broad  ligaments  in  adults. 

The  size  of  the  tubes  is  variable:  and  they  often  present  dilatations,  and 
sometimes  true  cysts  filled  with  a  citrine  fluid. 

M.  Follin  has  not  been  able  to  discover  an  excretory  orifice  to  these  tubes, 
either  in  young  girls  or  adult  women. 

Their  structure  resembles  that  of  the  glandular  tubes  of  many  simple 
glands.  They  are  provided  with  a  central  cavity,  which  presents  the  dila- 
tations so  often  observed  in  tubes  of  this  class.  Externally,  the  tube  is 
formed  of  cellular-tissue-membrane  with  longitudinal  fibres.  The  internal 
surface  of  the  tube  is  covered  with  pavement  epithelium. 

Some  observations  are  calculated  to  produce  the  impression,  without  how- 
ever confirming  it,  that  this  assemblage  of  tubes  has,  in  its  origin,  some 
relation  with  the  corpora  Wolffiana. 

Attached  to  the  free  edge  of  the  broad  ligaments,  it  is  not  uncommon  to 
find  five,  six,  or  even  more  small  cysts.  They  are  generally  connected  with 
the  ligament  by  a  very  slender  pedicle,  of  variable  length,  but  which  is 
sometimes  so  short,  that  the  cyst  appears  to  be  sessile,  and  directly  adherent 
to  the  ligament.     (See  Fig.  28.) 

It  is  difficult  to  understand  the  mode  of  the  development  of  these  cysts. 
They  may,  perhaps,  have  some  relation  with  the  tubes  of  which  the  bodies 


84 


FEMALE  ORGAN'S  OF  GENERATION". 


of  Rosenmuller  are  composed.  It  has  however  seemed  to  us  worth  while  to 
call  attention  to  them  particularly,  as  they  are  stated  by  M.  Broca  to  be 
present  in  the  great  majority  of  cases. 

The  round  ligaments,  or  supra-pubic  cords,  are  evidently  continuous  with 
the  tissue  of  the  uterus,  to  which  their  proper  substance  is  precisely  similar; 
arising  from  the  lateral  border  of  this  organ,  below  and  a  little  in  advance 
of  the  Fallopian  tube,  it  runs  upwards  and  outwards.  According  to  M. 
Deville,  this  fringe,  or  ligament,  is  bent  downward  in  the  anterior  fold  of  the 
broad  ligament,  and  reaches  the  internal  orifice  of  the  inguinal  canal,  i-ato 

Fio.  28. 


The  figure  exhibits  the  small  cysts  appended  t  i  the  free  edge  of  the  broaii  ligaments.    One  of  the  Fallopian 

tubes  is  repr  -  nted  with  a  double  fimbriated  extremity,  as  in  the  case  described  by  Q,  Richard. 
4.  L't'-nis.     b.  Fallopian  tubes,     o.  The  additional  fimbriated  extremity,      n,  e.   'J  he  normal  fimbriated 
r-xtreniities.    f,  o,  n.  The  cysts  described  above. 

which  it  enters,  accompanied  by  a  prolongation  of  the  peritoneum,  bearing 
the  name  of  the  Canal  of  Nuck.  It  then  divides  into  a  number  of  fibrous 
fasciculi,  which  are  lost  in  the  cellular  tissue  of  the  mons  veneris  and  that 
which  fills  the  dartoid  sac,  described  as  existing  in  the  labia  externa.  Ac- 
cording to  Madame  Boivin,  the  round  ligament  on  the  right  side  is  the 
shorter  and  larger  of  tlie  two.  They  contain  a  great  number  of  veins, 
which  are  liable  to  become  varicose. 

These  ligaments  serve  to  retain  the  uterus  in  position,  and  to  prevent  its 
displacements ;  and  it  is  probably  to  them  that  the  pains  in  the  groins, 
experienced  by  some  women  during  chronic  affections  or  displacements  of 
the  womb,  may  be  referred.  They  are,  in  a  great  measure,  composed  of 
cellular  tissue  and  vessels,  but  containing  also  some  muscular  fasciculi,  the 
superior  of  which  are  prolonged  from  the  uterus,  and  the  inferior  come  from 
the  transversalis  muscle.  The  superior  muscular  fibres  are  much  more 
evident  during  pregnancy. 

Finally,  the  vesico-vAerine  and  utero-sacral  ligaments,  formed,  as  we  have 
stated,  of  folds  of  the  peritoneum,  which,  after  having  covered  the  uterus, 
are  reflected  upon  the  posterior  surface  of  the  bladder  and  the  anterior  sur- 
face of  the  rectum ;  these  ligaments  are,  so  to  speak,  reinforced  by  collec- 
tions of  fibres  which  appear  to  be  prolongations  from  the  tissue  proper  of 
the  womb,  and  which  are  attached  anteriorly  to  the  posterior  surface  of  the 
bladder,  and  posteriorly  to  the  anterior  surface  of  the  rectum. 


INTERNAL     ORGANS    OF    GENERATION.  85 

ARTICLE   III. 

OF   THE   FALLOPIAN   TUBES. 

The  uterine  or  Fallopian  tubes  are  two  canals,  varying  from  four  and  n 
quarter  to  five  inches  in  length,  and  placed  in  the  thickness  of  the  superior 
border  of  the  broad  ligament.  They  extend  transversely  from  the  lateral 
angles  of  the  womb  nearly  to  the  -iliac  fossa  on  the  corresponding  side. 
Their  volume  is  made  more  evident  by  inflating  them.  (G.  Richard.)  It 
may  then  be  ascertained  that  beyond  the  uterine  parietes,  the  tube  has  a 
diameter  of  about  three-sixteenths  of  an  inch  ;  towards  the  middle  of  its 
course  it  increases  to  about  one-quarter  of  an  inch,  and  just  before  the 
ostium  abdominale,  to  five-sixteenths  of  an  inch.  Their  calibre  is  very 
variable  at  different  points.  The  elasticity  of  the  walls  is  however  so  great 
as  to  allow  of  their  increase  to  an  enormous  extent,  as  is  proved  by  the  cysts 
which  are  frequently  found  in  them. 

The  internal  orifice  of  the  tube  (ostium  uterinum)  is  stated  by  M.  Richard 
to  be  the  one-sixteenth  of  an  inch  in  diameter ;  from  thence,  the  calibre  of 
the  canal  increases  gradually  to  its  external  orifice.  Near  the  free  extremity 
it  spreads  out  and  becomes  fringed.  This  termination  constitutes  the  pavil- 
ion, or  fimbriated  extremity  (the  morsus  diaboli). 

It  is  generally  taught  that  one  of  these  fringes,  which  is  longer  than  the 
others,  attaches  itself  to  the  extremity  of  the  ovary.  On  the  contrary,  M. 
Cruveilhier  believes  that  this  adherence  takes  place  through  the  interven- 
tion of  a  groove,  the  concavity  of  which  looks  downwards  and  backwards, 
and  facilitates  the  communication  between  the  ovary  and  the  cavity  of  the 
tube.  All  the  fringed  folds  are  attached  to  a  small  circle  which,  is  more 
contracted  than  the  part  of  the  tube  which  it  terminates.  This  small  circle 
is  called  the  external  orifice  of  the  tube.  The  internal  or  uterine  orifice  is 
the  name  given  to  the  one  by  which  it  opens  in  the  uterine  cavity. 

[The  Fallopian  tubes  are  composed  of  three  layers :  an  external  or  serous,  a  middle 
or  muscular,  and  an  internal  or  mucous  layer. 

The  external  layer  is  a  part  of  the  peritoneum  which  lines  the  entire  length  of 
the  oviduct,  and  is  extended  to  the  free  edge  of  the  fimbriated  extremity,  where  it 
ends  abruptly. 

The  middle  layer  is  composed  of  two  planes  of  muscular  fibres  —  the  external 
being  longitudinal,  and  the  internal  circular.  The  tubes  have  often  been  described 
as  prolongations  of  the  uterus,  whereas  M.  Robin  regards  them  as  entirely  dis- 
tinct. A  thin,  cellular  septum  is,  in  fact,  interposed  between  the  tissues  of  the 
two  organs,  allowing  of  their  separation  by  the  scalpel. 

The  mucous  layer  is  continuous  internally  with  the  uterine  mucous  membrane, 
and  terminates  externally  upon  the  free  edge  of  the  fimbriated  extremity  where  it 
is  connected  with  the  peritoneal  layer.  Thus  affording  the  only  example  of  a 
mucous  membrane  in  continuity  with  a  serous  one. 

The  mucous  membrane  of  the  oviduct  is  devoid  of  papilli  and  glands,  but  presents 
longitudinal  folds  so  adjusted  to  each  other  as  to  transform  the  canal  into  numerous 
capillary  tubes,  well  adapted  to  convey  readily  the  spermatic  fluid  to  the  ovary. 
The  mucous  membrane  is  also  covered  with  a  vibratilo  epithelium,  tin'  motion  of 
whose  cilia  being  directed  toward  the  uterus  are,  doubtless,  intended  to  impel  the 
jvuIj  toward  the  uterine  orifice  of  the  tube.] 


86  FEMALE  ORGANS  OF  GENERATION". 

A  special  artery,  derived  from  the  numerous  branches  with  which  the 
uterus  is  supplied,  and  two  veins,  which  join  the  ovarian  veins,  constitute 
the  vascular  apparatus  of  the  tube.  It  is  provided  with  nerves  from  the 
spermatic  and  hypogastric  plexuses. 

The  Fallopian  tube  serves  the  double  purpose  of  a  canal  for  transmitting 
the  fecundating  principle  of  the  male,  and  for  carrying  the  germ  furnished 
by  the  female  from  the  ovary  to  the  uterus. 

Injections  into  the  uterus  may  pass  through  the  Fallopian  tubes  into 
the  peritonea]  cavity  and  be  a  cause  of  peritonitis. 

At  each  menstrual  period  the  ovule  passes  with  the  serum  current  along 
the  ovarian  fimbriae  into  the  Fallopian  tube.  At  this  time,  the  vessels  of  the 
Fallopian  tubes  arc  engorged — the  mucous  membrane  assumes  a  well-marked 
nd  color — the  walls  are  thickened,  and  the  canal  is  enlarged.  The  tubes 
arc  at  the  same  time  affected  with  peristaltic  contractions,  which  are  prob- 
ably intended  to  propel  the  ovule  into  the  uterine  cavity. 

The  anomaly  presented  by  the  existence  of  supernumerary  pavilions,  or 
fimbriated  extremities,  upon  the  same  tube,  as  described  by  M.  Gustave 
Richard,  is  here  deserving  of  notice.  In  the  bodies  of  twenty  women, 
selected  at  random,  he  observed  it  five  times.  One  or  several  of  them  were 
found  attached  to  the  tube  either  immediately  behind  the  normal  fimbriated 
extremity,  or  at  distances  varying  from  three-quarters  of  an  inch  to  an  inch 
and  a  quarter  beyond  it ;  all  of  them  were  formed  like  the  one  which 
terminated  the  oviduct  by  the  fringe-like  division  of  the  mucous  membrane. 
By  floating  the  fringes  under  water,  an  opening  was  discovered  conducting 
into  the  tube,  through  which  a  stylet  might  be  introduced  and  brought  out 
through  either  the  internal  or  external  orifice  of  the  tube. 

According  to  Dr.  Hamilton,  of  Edinburgh,  the  Fallopian  tube  undergoes 
some  modification  during  gestation,  to  which  he  attaches  great  importance. 
as  a  characteristic  sign  of  pregnancy.  This  change  consists  in  the  forma- 
tion of  a  little  pocket,  or  sac,  about  an  inch  from  the  fringed  extremity. 
This  partial  dilatation  of  the  tube,  previously  described  by  Roederer  under 
the  name  of  antrum  tubce,  is  certainly  an  exceptional  fact.  I  have  never 
observed  it ;  and  M.  Montgomery  has  encountered  it  but  once  in  fourteen 
uteri,  examined  in  the  state  of  gestation ;  so  that  it  cannot  have  all  the  im- 
portance that  certain  authors  wish  to  ascribe  to  it. 

ARTICLE  IV. 

OF   THE   OVARIES. 

The  ovaries  (testes  muliebres)  are  the  analogues,  in  the  female,  to  the  testi- 
cles of  the  male:  that  is,  both  of  them  secrete  a  product  indispensable  to 
reproduction.  Two  in  number,  they  are  situated  on  the  sides  of  the  uterus, 
in  that  portion  of  the  broad  ligament  called  the  posterior  wing,  just  behind 
the  Fallopian  tube.  They  are  maintained  in  position  by  those  ligaments, 
as  also  by  a  special  one,  denominated  the  ligament  of  the  ovary. 

The  ovaries  vary  in  situation,  according  to  the  age  of  the  individual,  and 
the  state  of  the  uterus.  In  the  foetus,  they  are  placed,  like  the  fundus  uteri, 
in  the  lumbar  region  ;  but,  during  gestation,  they  rise  into  the  abdomeD 
alons  with  the  body  of  the  uterus,  upon  the  sides  of  which  they  lie. 


INTERNAL    ORGANS    OF    GENERATION. 


87 


Immediately  after  delivery  the  ovaries  occupy  the  iliac  fossse,  where  they 
fcometimes  continue  throughout  life;  again,  it  is  not  at  all  uncommcn  to 
iind  them  turned  backwards,  and  adherent  to  the  posterior  face  of  the  womb 

The  ovaries  vary  in  size,  both  from  age,  from  the  plenitude  or  vacuity  of 
the  uterus,  and  from  health  or  disease.  Being  proportionably  larger  in  tl  e 
foetus  than  in  adult  age,  they  diminish  after  birth,  augment  in  volume  at 
puberty,  especially  at  the  monthly  periods,  and  dwindle  away  in  old  age. 
During  pregnancy  and  after  delivery,  they  acquire  in  some  cases  quite  a 
considerable  volume. 

Fio.  29. 


Ovary  of  the  Young  Female  after  Puberty. 

A.  Body  of  the  orary.    b.  Otero-ovarian  ligament,    c.  Tubo-ovavian  ligament,    d.  Fallopian  tubi . 

E.  Fimbriated  extremity  of  the  tube. 

Before  the  age  of  puberty,  the  external  surface  of  the  ovaries  is  of  a  Jight 
rose  color,  and  is  smooth  and  free  from  inequalities.  In  women  who  have 
menstruated  for  several  years  the  surface  is  rough,  fissured,  covered  with 
small  blackish  cicatrices,  and  sometimes  with  ecchymotic  spots.  Some  of 
these  cicatrices  are  linear,  others  are  triangular  or  radiated ;  they  are  of  a 
red  color  when  recent,  but  become  brown  in  the  course  of  a  few  months. 
Sometimes  a  complete  union  fails  to  take  place  between  their  edges,  leaving 
a  small  opening,  which  communicates  with  the  ruptured  cavity.  After  the 
period  of  life  at  which  the  menses  disappear,  the  external  surface  presents 
numerous  wrinkles,  which  are  not,  as  has  been  supposed,  the  result  of  old 
cicatrices,  but  are  due  simply  to  the  atrophy  of  the  ovaries,  and  the  plica- 
tion of  the  external  envelope  which  is  the  consequence. 

The  ovaries  are  ovoidal  in  shape,  a  little  flattened  from  before  backwards, 
and  of  a  whitish  color. 

The  external  extremity  of  the  ovary  is  adherent,  as  we  have  said,  to  one 
of  the  fringes  of  the  fimbriated  extremity  of  the  Fallopian  tube;  the  internal 
extremity  is  attached  to  the  uterus  by  the  ligament  of  the  ovary,  which  it 
inserted  at  the  corresponding  angle  of  that  organ. 

The  ligament  of  the  ovary,  which  we  have  already  considered,  was  for  a 
long  time  regarded  as  a  canal,  designed  like  the  Fallopian  tube  to  convoy 
the  fecundated  ovule  into  the  cavity  of  the  uterus;  modern  anatomy,  how- 
ever, proves  it  to  be  solid. 

From  the  researches  of  Gartner,  of  Copenhagen,  and  of  M.  de  Blainyille, 
it  appears  that  in  some  quadrupeds,  and  especially  the  sow,  a  canal  i? 
almost  always  to  be  found  extending  from  its  external  orifice  by  the  iide 


83  FEMALE  ORGANS  OF  GENERATION. 

of  the  meatus  urinarius  (corresponding  with  a  similar  orifice  on  the  othei 
side  of  the  meatus),  through  the  substance  of  the  muscular  fibres  of  the 
vagina  to  the  neck  of  the  uterus ;  here  the  canal  becomes  narrower,  but 
continues  on,  following  the  body  of  the  uterus  and  imbedded  in  its  fibrous 
structure,  and  finally  leaves  it  to  pass  in  a  direction  parallel  to  the  corre- 
sponding angle  into  the  substance  of  the  broad  ligament. 

M.  Follin  found,  whilst  injecting  the  duct  of  Gartner  in  the  sow,  that  he 
injected  at  the  same  time  a  long  tortuous  tube,  situated  in  the  substance  of 
the  ligament,  at  the  point  occupied  in  the  human  female,  by  the  collection 
of  glandular  tubes  which  I  have  described.  I  have  been  able  to  determine 
the  fact  that  in  the  sow  this  duct  does  not  open  by  a  large  orifice  at  the 
lower  part  of  the  vagina,  as  has  been  represented,  but  in  reality  by  a  very 
narrow  one.  It  is  not  terminated  at  its  entrance  into  the  broad  ligament 
by  a  few  brush-like  divisions,  as  stated  by  M.  de  Blainville,  but  is  continuous 
with  a  very  fine  tortuous  tube  which  extends  to  the  external  extremity  of 
that  ligament.  The  duct  of  Gartner  is  furnished  internally  with  a  pavement 
epithelium,  and  communicates  throughout  its  course  with  many  glandular 
tubes  finer  than  itself.     (Follin.) 

We  have  sought  for  this  duct  of  Gartner  in  the  human  female,  but  found 
nothing  which  could  be  reconciled  with  the  description  given  by  him  of  it; 
however,  we  cannot  avoid  remarking  that  since  these  researches  N.  C. 
Baudelocque  has  observed  in  a  woman  a  canal  which  seemed  to  be  pro- 
duced by  a  bifurcation  of  the  Fallopian  tube,  and  which,  after  passing 
through  the  entire  uterine  walls,  opened  into  the  upper  part  of  the  vagina 
near  the  neck  of  the  womb.  Madame  Boivin  and  some  others  have  met 
with  a  similar  canal,  and  Mauriceau  and  Dulaurens  considered  it  of  quite 
frequent  occurrence. 

The  arteries  which  supply  the  ovary  are  the  spermatics,  and  proceed 
directly  from  the  aorta. 

The  numerous  small  venous  branches  found  in  the  ovary  unite  below  the 
organ  so  as  to  form  a  plexus  which  gives  origin  to  the  ovarian  veins;  th^ 
latter  emptying  into  the  vena  cava  inferior,  and  into  the  renal  vein. 

The  numerous  lymphatic  vessels  with  which  it  is  provided  contribute  to 
the  formation  of  the  spermatic  plexus,  which  itself  empties  into  the  lumbar 
plexus,  and  thence  passes  to  the  thoracic  duct. 

The  nerves  are  derived  from  the  great  sympathetic. 

§  1.  Structure  of  the  Ovaries. 

[The  ovary  consists  of  a  special  parenchyma  inclosed  by  two  envelopes,  one  ot 
which  is  serous,  the  other  fibrous. 

The  serous  envelope  is  formed  by  the  peritoneum  and  is  closely  attached  to  the 
subjacent  one.  It  covers  the  entire  gland  except  at  its  lower  edge,  where  the  two 
layers  of  peritoneum  separate  to  allow  passage  for  the  vessels  and  nerves  distributed 
to  the  ovary. 

The  fibrous  envelope  corresponds  with  the  peritoneum  by  its  external  surface, 
whilst  its  internal  surface  is  blended  with  the  glandular  parenchyma.  It  is  much 
thinner  than  the  tunica  albiiginea  of  the  testicle  with  which  it  has  been  compared. 
M.  Sappey  even  denies  its  existence,  and  regards  the  peritoneum  as  the  only 
envelope  of  the  organ ;  his  opinion,  however,  is  not  yet  adopted  by  most  anatomists. 


INTERNAL     ORGANS     OF     GENERATION. 


89 


Within  the  envelopes  mentioned,  is  a  special  tissue  of  a  grayish-white  color, 
termed  the  stroma,  which  is  formed  in  great  part  hy  the  interlacement  of  muscular 
fibres,  some  of  which  are  peculiar  to  the  ovary,  whilst  others  are  but  a  prolongation 
of  the  same  kind  of  fibres  as  constitute  the  ligament  of  the  organ.  Other  fibres 
take  their  origin  from  the  Fallopian  tube.  The  existence  of  all  these  fibres  was 
shown  by  M.  Rouget  in  1858.  With  the  muscular  fibres  are  mingled  others  of 
connective  tissue. 

The  arteries  are  situated  between  the  muscular  fibres,  are  flexuous,  and  have  a 
spiral  form.  The  veins,  contorted  in  like  manner,  form  a  rich  network  which 
empties  into  a  venous  plexus  immediately  below  the  ovary.  The  arteries  and  veins, 
surrounded  as  they  are  by  muscular  fibres,  form  a  true  erectile  organ,  and  the  ovary 
is  regarded  as  such  by  M.  Rouget. 

Within  the  fibrous  structure  of  the  stroma  exist  small  cavities,  called  ovisacs  or 
Graafian  vesicles,  of  a  size  varying  ordinarily  from  that  of  a  millet-seed  to  that  of 
a  hemp-seed.  Some  of  the  more  developed  vesicles  project  from  the  surface  of  the 
ovary,  where  they  acquire,  as  we  shall  see  hereafter,  a  comparatively  large  size. 

About  fifteen  or  twenty  vesicles  may  be  readily  distinguished  in  the  adult  female, 
but  with  the  microscope  many  more  are  observable,  all  of  which  will  be  developed 
when  the  first  shall  have  disappeared. 

Fig.  30. 


12 


^>V' 


is  rr7 

ii 

Section  of  ovary. 

1.  Cortical  portion  containing  the  ovisacs  and  ovules.    2,  3,  4,  5.  6,  7.  8.   Follicles  in  different  stages     • 

development.  9.  Epithelium  oi  the  follicle  (meiubrana  granulosa).  10,  11.  Ovum  with  the  discus  proligerus, 

M.  Sappey's  microscopical  examinations  have  shown  that  in  one  healthy  ovary 
of  a  woman  of  from  eighteen  to  twenty  years  of  age,  the  number  of  ovisacs  and 
ovules  is  more  than  300.U0<>,  making  near  700,000  for  the  individual.  He  therefore 
calculates,  that  if  all  the  ova  existing  in  the  surface  oi  the  ovaries  of  a  young 
woman  were  to  be  fecundated  and  undergo  all  their  phases  of  development,  it 
would  require  but  one  woman  to  populate  four  Buch  cities  as  Lyons,  Marseilles, 
Bordeaux,  and  Rouen,  and  but  two,  to  furnish  inhabitants  for  a  capital  like  Paris, 
containing  1,600,00(1  souls. 

There  are  as  many  ovisacs  in   the  foetus  as  there  will  be  at  pubfrty,  but  as  the 


ao 


FEMALE  ORGANS  OF  GENERATION. 


gland  is  tlien  small,  the  vesicles  conglomerated,  but  separate  as  the  ovary  dovtlopa 
After  puberty,  the  number  of  ovisacs  lessens  ;  in  old  women  tbey  disappear. 

§  2.  Of  the  Ovarian  Vesicles. 

From  birth  to  puberty  the  Graafian  vesicles  undergo  no  change.  They  have  a 
rounded  form  and  a  diameter  of  y^-j  of  an  inch.  At  puberty  some  of  them  hav* 
become  developed,  and.  as  stated,  have  attained  the  size  of  a  millet-seed,  of  a  hemp 
seed,  or  even  of  a  pea. 

Each  vesicle  adheres  firmly  to  the  substance  of  the  stroma  in  which  it  is  lodged, 
and  which  forms  for  it  a  sort  of  retractile  tegument.  The  special  structure  of  each 
ovisac  consists:   1,  in  a  capsule  or  envelope;  2,  of  a  contained  body  or  nucleus. 

1.  The  capsule  or  envelope  is  formed  of  a  special,  transparent,  extremely  thin, 
but  resisting,  non-contractile  membrane.  It  is  vascular  and  forms  the  vesicle  con 
taining  the  nucleus.] 

2.  The  Nucleus. — The  parts  entering  into  the  composition  of  the  nucleus 
are:  1st,  a  granular  membrane  which  incloses  the  humor  of  the  Graafian 
vesicle;  and  2d,  a  liquid  produced  by  the  aggregation  of  three  humors  of 
a  different  aspect,  viz.,  a  limpid  mucosity,  clear,  though  a  little  oily,  a 
number  of  small  rounded  granulations,  transparent  in  their  central  cavity, 
and  slightly  opaque  at  their  periphery,  and  some  oil  globules.  3d,  and 
lastly,  an  ovule  floating  in  the  midst  of  this  liquid. 

The   Granular  Membrane  (see  Fig.  31,  g').  —  A  delicate   membrane  is 
Via.  3i.  found  applied  on  the  internal  face  of  the 

Graafian  vesicle,  formed  of  granules,  or 
rather  of  cellules,  and  bearing  the  name 
of  the  granular  membrane.  It  tears  with 
great  facility,  from  its  extreme  tenuity ; 
and  hence  many  authors  have  denied  its 
existence.  Upon  one  part  of  the  mem- 
brane (that  corresponding  to  the  free  side 
of  the  vesicle)  the  granulations,  or  cells 
producing  it,  are  more  numerous  or  more 
compact,  and  in  the  centre  of  this  com- 
pact mass,  which  has  been  called  the  pro- 
ligerous  disk,  the  ovule  is  found. 

The  granulations,  constituting  the  pro- 
ligerous  disk  (see  G,  Fig.  31),  are  so  closely 
united  both  with  each  other  and  with  the 
latter,  that  upon  opening  the  Graafian  vesicle,  even  where  the  granular 
membrane  is  destroyed,  this  portion  remains  adherent  to  the  ovule,  forming 
round  it,  as  it  were,  a  granular  bed.  This  membrane  is  entirely  destitute 
of  vessels. 

§  3.  The  Ovule. 

Since  the  labors  of  Graaf,  the  majority  of  authors  agree  with  him,  that 
the  ovule  is  constituted  by  the  vesicle  just  described;  but  the  honor  of 
baying  first  discovered  the  ovule,  as  a  distinct  organ  in  this  vesicle,  belongs 
to  Charles  Ernest  Baer.  The  ovule  is  completely  formed  in  the  ovary 
during  the  earlier  years  of  life.  It  is  imbedded  from  the  period  of  its 
maturity,  as  stated  above,  in  the  midst  of  a  mass  of  granulations,  which 
are  moie  compac'  than  those  which  fill  the  remainder  of  tbp.  vosielp 


Ovule  in  the  Graafian  vesicle. 
A.  Ovule.  B.  Cumulus  granulosus.  C.  Gran- 
ular membrane.  r>.  Cavity  of  the  Graafian 
vesicle.  E.  Membrane  proper  of  the  ovisac. 
F.  Stroma  of  the  ovary,  o  Fibrous  envelope 
of  the  ovary,     a.  Peritoneal  layer  of  the  ovary. 


INTERNAL    ORGANS    OF    GENERATION. 


91 


It  therefore  occupies  a  fixed  position  in  the  vesicle,  and  is  almost  con 
Btantly  met  with  at  a  point  opposite  to  that  whence  the  large  vascular 
trunks  spread  out  upon  the  ovarian  capsule,  that  is  to  say,  at  the  point 
which  projects  from  the  surface  of  the  ovary.  When  examined  with  a 
lens,  it  appears  as  an  opaque  rounded  body,  at  least  more  opaque  than  the 
liquid  inclosed  in  the  same  vesicle ;  it  is  extremely  minute,  although  the 
diameter  of  the  little  sphere  it  represents  is  subject  to  variations. 

"The  largest  human  ovules  I  have  seen  and  manipulated,"  says  Bisch^rT. 
"did  not  exceed  the  tenth  of  a  line,  being  barely  perceptible  to  the  naked 
eye."  When  placed  under  a  microscope,  it  is  seen  to  consist  of  an  exterior 
envelope,  called  the  vitelline  membrane  (Coste),  transparent  zone,  cortical 
membrane,  or  chorion  (Baer),  of  a  substance  aptly  compared  to  the  yolk 
of  an  egg,  and  designated  as  the  vitellus,  and 
of  another  vesicle  (placed  within  the  latter)  Fig.  32. 

called  the  germinal  vesicle.  ^      ^^-^ 

A.  Vitelline  Membrane.  —  If  the  ovule  be 
examined  by  a  magnifying  glass  of  sufficient 
power,  an  obscure  sphere  will  be  brought  into 
view,  surrounded  by  a  large  clear  ring,  the 
nature  of  which  it  is  difficult  to  make  out.  M. 
Coste  has  given  the  name  of  the  vitelline  mem- 
brane to  this  ring.  It  is  evidently  a  thick 
membrane,  the  external  and  internal  outlines 
of  which  assume  the  appearance  of  two  circular 
lines  inclosing  a  transparent  ring.  Many  per- 
sons have  merely  considered  it  as  a  layer  of 
albumen  surrounding  the  yolk,  but  any  one  parent  zone.    b.  The  viteiius,  or  yolk. 

-!  .  ,  .  1%   ,1      ,     -,    •         ,1         ,     c.  Tlie  vesicle  of   I'urkinje,  or  tlie  ger- 

may  easily  convince  himself  that  it  is  at  least   ni3nul  vesicle,  d.  The  germinal  spot, 
a  resisting  membrane,  by  cutting  the  ovule,  or 

by  compressing  it  by  means  of  an  instrument  called  the  compressor ;  "  for 
after  proceeding  in  this  manner,"  says  Bischoff,  "there  cannot  be  a  doubt 
that  the  transparent  zone  is  an  elastic,  thick,  hyaline,  and  transparent 
membrane,  without  a  determinate  texture." 

Though  entirely  destitute  of  cells  and  vessels,  it  is  nevertheless  a  living 
envelope;  because,  as  soon  as  the  ovum  in  the  mammalia  arrives  in  the 
cavity  of  the  uterus,  it  becomes  the  seat  of  an  active  vegetation,  and  pro- 
duces villosities  which  are  more  or  less  ramified.  The  latter,  as  they 
become  developed,  insinuate  themselves  into  the  tissue  of  the  uterine 
mucous  membrane,  and  thus  attach  the  ovum  to  the  place  which  it  is  to 
occupy  for  the  future. 

B.  Yolk  or  Vitellus.  —  The  cavity  of  the  vitelline  membrane  is  occupied, 
in  great  measure,  by  a  granular  liquid,  that  does  not  adhere  to  the  ex- 
terior envelope,  and  even  escapes  from  it  readily  when  the  latter  is  broken. 

According  to  Bischoff,  the  yolk  of  a  human  ovum  is  formed  of  a  coher- 
ent, indistinctly  granular,  transparent,  and  viscous  mass,  which  does  not 
run  out  when  the  egg  is  cut  or  crushed  ;  each  portion  of  the  zone  leserving 
its  particular  segment  or  yolk,  or  the  hitter  escaping  altogether. 

"In  certain  cases,"  says  he,  "the  vitelline  granulations  are  not  united  In 


A  Non-fecundated  Human  Ovule. 
A.  The  vitelline  membrane,  or  tram- 


92  FEMALE  ORGANS  OF  GENERATION. 

a  single  mass.     I  have  seen  the  yolk  divided  in  two,  and,  on  one  occasion, 
into  five  parts  of  different  volume." 

The  vitellus  usually  fills  the  interior  of  the  zone  completely,  and  has  the 
same  form,  but  sometimes  the  vitelline  sphere  is  smaller  than  that  destined 
to  receive  it.  Some  authors  likewise  believe  that  a  very  delicate  membrane 
exists,  which  incloses  and  unites  the  yolk  in  a  single  mass ;  but  Messrs. 
Coste  and  Bischoff  agree  in  rejecting  the  existence  of  this,  and  contend 
that  the  granulations  of  the  vitellus  are  placed  in  juxtaposition  with  the 
transparent  zone,  whioh  forms  its  sole  and  only  envelope. 

c.  Germinal  Vesicle. — In  the  midst  of  the  vitellus,  in  very  young  girls, 
or  on  one  of  the  neighboring  points  of  the  peripheral  envelope  in  the  matured 
ovules,  a  small,  perfectly  transparent,  and  colorless  vesicle  is  seen  like  a 
clear  spot,  surrounded  by  a  mass  of  a  deeper  yellow.  Purkinje  had  described 
it  in  the  eggs  of  birds,  and  gave  his  own  name  to  it;  but  M.  Coste  is  entitled 
to  the  honor  of  having  first  demonstrated  its  existence  in  the  ovum  of 
mammifera},  and  of  thus  having  established  the  perfect  identity  between  the 
latter  and  the  eggs  of  birds.  This  is  the  vesicle  of  Purkinje,  or  the  germ  and 
vesicle.  It  is  slightly  oval,  and  consists  of  a  very  delicate,  transparent,  and 
colorless  membrane,  which  incloses  a  liquid  that  is  frequently  as  limpid  and 
transparent  as  itself,  though  it  sometimes  contains  a  few  granules.  Notwith- 
standing its  extreme  tenuity,  this  vesicle  still  offers  a  certain  consistence, 
since  it  has  been  seen  intact,  after  leaving  the  ovule,  and  being  completely 
separated  from  the  granular  liquid  in  which  it  was  placed. 

It  is  always  very  small,  and  scarcely  measures  the  sixtieth  of  a  line  in 
diameter. 

d.  The  Germinal  Spot.  —  If  the  germinal  vesicle  be  attentively  observed, 
an  obscure  rounded  spot  will  be  seen  on  some  part  of  its  periphery ;  this  was 
first  discovered  by  Wagner,  who  gave  it  the  name  of  the  germinal  spot.  It 
seems  to  be  formed  by  the  aggregation  of  fine  small  granules,  or  little 
globules,  the  obscure  hue  of  which  is  brought  out  by  the  clear  contents  of 
the  vesicle.  Wagner  has  sometimes  met  with  two,  or  even  more,  germinal 
spots  in  the  mammiferce. 

Before  fecundation,  therefore,  the  ovule  is  composed :  1st,  of  an  exterior 
envelope,  the  vitelline  membrane,  or  transparent  zone  ;  2d,  of  a  vitellus,  or 
yolk,  contained  in  this  vesicle;  3d,  of  a  little  vesicle  inclosed  in  the  first 
and  swimming  in  the  vitelline  fluid  —  the  germinal  vesicle;  4th,  and  lastly, 
of  the  germinal  spot. 

EXPLANATION  OF  PLATE  I. 

MEDIAN    PERPENDICULAR   SECTION    OF    PELVIS    FROM    FRONT   TO 
BACK,    SHOWING    BOTH    PELVIC   SPACES. 
[Taken  from  Savage  on  the  Female  Pelvic  Organs.'] 
a.  Anus,  marking  the  columns  of  Morgagni.     it.  Rectum,  projections  in  the  cavity, 
the  valves  (?)  of  Houston.      These   folds   include   all  the  coats  of  the  rectum,  and  are 
readily  etfaceable  by  slight  distension.     Note  minute  circular  markings  at  the  anal  end, 
indicating  transverse   Bections  of  the  inferior  circular  fibres    of  the   rectum  (internal 
sphincter),  and  lines  near  the  coccyx  indicating  the  posterior  half  of  external  sphinc- 
ter, the  coccygeal  attachment  of  the   pubo-coccygeal  muscle,  and  the  recto-coccygeus 


OVULATION    AND    MENSTRUATION.  93 

muscle,  or  retractor  recti,  Luschka.  u.  Left  half  of  the  uterus;  its  central  more  vas- 
cular, erectile  portion  surrounded  by  its  internal  and  external  muscular  cortex  ;  its 
cavity  a  mere  rima  between  its  antero-posterior  surfaces,  v.  Vagina,  its  muscular 
coats  gradually  losing  themselves  on  the  uterine  neck  up  to  its  junction  with  the 
uterine  body.  b.  Bladder,  moderately  distended  ;  its  outer  longitudinal  coat  in  front 
passing  off  to  its  attachments  to  the  inferior  edge  of  the  pubic  symphysis,  and  to  the 
ligamentous  process  of  the  pubo-coccygeal  muscle,  bridging  over  the  urethro-pubic 
venous  plexus,  separating  that  space  from  the  vesico-pubic  space  above,  which  is 
bridged  over  by  the  vesical  ligaments  formed  by  the  urachus  and  two  remnants  of 
the  hypogastric  arteries,  c.  Section  of  Clitoris,  l.  Vulvar  labium,  i.  Nympha.  v. 
Perineal  body,  black  dots  indicating  the  site  of  its  many  small  vessels;  behind  it, 
anterior  sections  of  the  lower  circular  fibres  of  the  rectum  (internal  sphincter), 
s.  Pubic  symj)hysis  and  vesico-pubic  space,  u.  Urethra,  inner  longitudinal  muscular 
coat  surrounded  by  m,  m,  outer  circular  coat,  those  at  u  constituting  a  true  compound 
sphincter  composed  of  organic  and  voluntary  muscular  fibres,  p,  P.  Vesico-uterine  and 
recto-uterine  (Pouch  of  Douglas)  peritoneal  folds. 


CHAPTER  IV. 

OVULATION   AND   MENSTRUATION. 

Another  physiological  phenomenon,  namely,  menstruation,  is  both  ex- 
cited by  and  dependent  upon  the  evolution  of  the  Graafian  vesicles  or  ovu- 
lation. Ovulation  and  menstruation  are,  therefore,  intimately  connected 
and  should  be  studied  consecutively. 

ARTICLE    I. 

OF   THE   MODIFICATIONS   UNDERGONE   BY   THE   OVARIAN   VESICLES. 

Until  the  age  of  puberty  the  Graafian  vesicles  are  of  small  size ;  but  at 
this  period,  some  fifteen  to  twenty  of  them,  which  appear  more  advanced 
than  the  others,  increase  in  size,  and  project  from  the  external  surface  of 
the  ovary.  At  the  time  when  the  young  girl  becomes  nubile,  one  of  the 
latter  vesicles  seems  to  have  received  a  great  increase  of  vitality ;  it  under- 
goes a  remarkable  hypertrophy,  and  forms  a  projection  upon  the  surface  of 
the  ovary  ;  this  projection  becomes  greater  and  greater  until  after  some  days 
it  forms  a  tumor  of  the  size  of  a  cherry,  or  even  of  a  small  nut,  upon  the 
ovarian  surface. 

This  considerable  augmentation  of  size  is  due  to  the  distention  of  the 
walls  of  the  vesicle  by  an  increased  secretion  of  the  fluid  which  it  contains. 
In  proportion  as  the  development  proceeds,  the  walls  of  the  vesicle  become 
thin ;  the  vessels  which  supply  them  being  compressed  by  the  dilatation, 
lose  their  volume  and  become  obliterated  and  atrophied,  especially  upon  the 
point  of  culmination,  where  the  resistance  is  least.  When  at  last  it  has  arrived 
at  its  full  development,  the  ovarian  capsule  appears  to  remain  stationary 
until  an  over-excitement,  produced  either  by  the  maturity  of  the  ovule,  01 
by  sexual  intercourse,  occasions  its  rupture.  (Coste.)  Then,  the  walls  of 
the  vesicle,  although  more  and  more  distended,  begin  to  lose  their  trans 


94 


FEMALE  ORGANS  OF  GENERATION. 


pareucy,  on  account  of  the  hemorrhage  which  ensues.  This  is  sometime.* 
limited  to  the  production  of  small  extravasations  upon  the  as  yet  entire 
walls  of  the  vesicle,  though  most  frequently  a  true  effusion  takes  place  within 
the  cavity.  The  effused  blood  and  the  superabundant  secretion  increase 
still  more  the  distention  of  the  walls,  which  is  finally  carried  so  far  that 
rupture  becomes  imminent,  and  it  is  possible  to  distinguish  at  the  most  pro- 
jecting part  of  the  tumor,  the  point  where  it  is  about  to  ensue.  This  point 
is  generally  indicated  by  a  small  reddish  spot,  of  about  a  line  in  extent, 
produced  by  a  strong  injection,  or  even  by  a  slight  effusion  of  blood  in  the 


Fia.  34. 


FlO.  33.  Showing  the  ovary,  and  a  Graafian  vesicle  at  its  highest  degree  of  development,  and  just  before  its 
•upture.  ' 

a.  The  hypertrophied  vesicle  (drawn  from  n  iture,  and  of  its  real  size),  b,  c,  c.  R  idi  ited  cicatrices,  left  by 
?reviously  ruptured  vesicles. 

Fw.  34.  The  ovary,  with  the  raptured  vesicle  and  the  large  clot  that  fills  its  cavity.    (Drawn  from  nature.) 

texture  of  the  walls  of  the  vesicle.  (Raciborsky.)  The  thinned  walls  finally 
give  way  and  tear  gradually  ;  the  membranes  of  the  vesicle  itself  being  the 
first  to  yield,  and  after  them  the  peritoneal  layer.  As  a  consequence  of  this 
rupture,  the  ovule  is  expelled,  and  carries  along  with  it  a  part  of  the  granular 
contents  of  the  vesicle  ;  it  enters  the  Fallopian  tube,  the  fimbriated  extremity 
of  which  is  prepared  to  receive  it,  and  after  traversing  its  canal  arrives  at 
a  later  period  in  the  cavity  of  the  uterus. 

The  walls  of  the  follicle  collapse  after  the  rupture,  and  its  cavity  becomes 
filled  with  a  small  quantity  of  blood,  which  is  found  fluid  or  coagulated 
according  to  the  time  at  which  the  examination  is  made. 

The  walls  of  the  torn  vesicle  contract  gradually,  and  the  clot,  which  some- 
times at  first  is  the  size  of  a  small  cherry,  is  slowly  absorbed ;  the  originally 
spacious  cavity  diminishes,  the  margins  of  the  rupture  approximate,  so  as 
even  to  become  united  occasionally  by  cicatrization,  and  order  is  finally 
restored. 

The  evolution  just  described,  which  is  terminated  by  the  rupture  of  a 
venicle  and  the  spontaneous  expulsion  of  an  ovule,  is  not  an  isolated  face ; 
on  the  contrary,  it  excites  numerous  sympathies  in  the  remainder  of  the  gen- 

1  This  figure,  borrowed  from  M.  Raciborsky,  is  the  exact  copy  of  a  preparation  which 
he  had  the  kindness  to  show  me.  But  since  that  time  (1843)  I  have  never  met  with  so 
enormously  developed  a  vesicle,  and  I  am  disposed  to  believe  that  this  great  size  is 
rather  pathological  than  normal. 


OVULATION"     AND    MENSTRUATION.  95 

erative  apparatus  and  throughout  the  organism  of  the  female.  We  shall  first 
study  the  generative  organs  and  the  modifications  which  they  undergo  before, 
during,  and  after  this  evolution. 

The  ovary,  which  produces  the  hypertrophied  vesicle,  is  notably  enlarged. 
It  is  of  a  deep  red  color,  and  its  vascular  apparatus  is  remarkably  con- 
gested. 

The  Fallopian  tube  itself  shares  in  the  congestion,  being  often  of  a  violet- 
red  color,  especially  at  its  fimbriated  extremity,  which  has  a  sort  of  velvety 
appearance.  It  is  also  endowed  at  this  time  with  a  special  erethism,  in 
virtue  of  which  it  applies  its  floating  extremity  upon  the  ovary,  in  such  a 
manner  as  to  receive  the  ovule  and  conduct  it  into  its  cavity. 

The  uterus  undergoes  such  important  changes  that,  before  the  discovery 
of  spontaneous  ovulation,  it  was  erroneously  supposed  to  play  the  principal 
part  in  the  phenomena  which  we  are  about  to  study.  I  shall  continue  to 
draw  from  the  beautiful  works  of  M.  Coste,  from  which  I  have  already  bor- 
rowed so  freely  in  the  preparation  of  this  chapter,  the  principal  features  of 
the  ensuing  description. 

Whilst  the  ovarian  vesicle  is  undergoing  the  rapid  evolution  which  we 
have  just  described,  the  vascular  apparatus  of  the  womb  becomes  developed 
and  injected  in  an  unusual  manner;  immediately  beneath  the  delicate  layer 
of  epithelium  which  covers  the  surface  of  the  mucous  membrane,  it  forms 
in  particular  elegant  reticulations,  with  irregular,  lozenge-shaped  intervals, 
surrounding  the  orifice  of  each  of  the  numerous  glandular  tubes  of  which 
this  membrane  is  almost  entirely  composed.  This  network  is  so  fine  as  to 
give  a  violet  hue  of  greater  or  less  intensity  to  the  internal  surface  of  the 
womb,  and  is  formed  of  very  delicate  venous  ramuscules.  The  utricular 
glands  increase  perceptibly  in  size,  and  the  muscular  structure  of  the  uterus, 
in  consequence  of  the  congestion  which  it  undergoes,  acquires  greater  exten- 
sion, is  of  a  more  lively  red  color,  and  becomes  more  spongy  and  supple. 
The  entire  volume  of  the  organ  is  increased,  the  neck  is  tumefied  and  its 
orifice  narrower;  the  lips  of  the  os  tincse  are  warmer  and  their  color  deeper. 

The  mucous  membrane,  in  consequence  of  this  development  of  its  vessels, 
and  especially  of  the  glandules  of  which  it  is  composed,  has  its  thickness 
so  much  increased  in  proportion  to  the  size  of  the  uterine  cavity,  as  to  be 
thrown,  in  a  great  many  subjects,  into  soft,  projecting  folds  or  circumvolu- 
tions, which  are  so  pressed  together  as  to  leave  no  vacant  space  in  the  cavity 
of  the  organ.  M.  Coste  has  several  wombs  in  his  possession,  whose  mucous 
membranes  measure  at  certain  points,  from  two  to  three-eighths  of  an  inch 
in  thickness ;  still,  to  whatever  degree  the  hypertrophy  may  be  carried,  it 
never  presents  the  floating  villi  which  Baer  and  Weber  thought  they  had 
observed ;  neither,  except  in  some  pathological  cases,  does  it  ever  exhibit 
the  pseudo-membranous  exudation  which  is  acknowledged  by  almost  all 
physiologists.     (See  Deciduous  Membrane.) 

This  great  vascularity  of  the  mucous  membrane,  and  the  high  vascular 
congestion  which  the  entire  organ  undergoes,  is  at  first  accompanied  with 
the  exudation  of  a  few  drops  of  blood,  which  by  admixture  below  with  the 
vaginal  mucus,  which  is  itself  at  this  period  increased  both  in  quantity  and 
fluidity,  communicates  to  it  at  first  a  rosy,  and   then   a  light  reddish  hue 


96 


FEMALE  ORGANS  OF  GENERATION. 


After  two  or  three  days,  a  flow  of  blood,  derived  principally  from  the  super- 
ficial network  of  the  mucous  membrane,  escapes  through  the  neck  and 
mingles  with  the  vaginal  secretions.  Henceforth,  the  effusion  presents  all 
the  characters  of  a  true  hemorrhage. 

There  can  be  no  doubt  that  the  chief  source  of  this  hemorrhage  is  the 
superficial  vascular  network  of  the  mucous  membrane;  and  in  women  who 
have  died  at  this  period  the  blood  may  be  seen  to  transude  through  micro- 
scopic fissures. 

The  flow  preserves  the  same  characters  during  the  two  or  three,  be  they 
more  or  less,  days  of  its  duration  ;  then,  as  the  quantity  of  blood  diminishes, 
it  resumes  gradually  the  mucous  and  serous  characters  peculiar  to  the  vagi- 
nal secretion. 

It  is  impossible,  in  the  present  state  of  our  knowledge  of  the  subject,  to 

determine  precisely  at  what  mo- 
ment during  the  flow  of  blood 
the  rupture  of  the  Graafian  vesicle 
takes  place.  The  result  of  numer- 
ous autopsies  admits  of  the  sup- 
position that  this  moment  is  vari- 
able, and  the  curious  experiments 
of  M.  Coste  leave  no  doubt  what- 
ever as  to  the  influence  which 
veneral  excitement  is  capable  of 
exerting  upon  it;  this  influence  is 
so  great,  that  it  may  determine 
the  rupture  of  an  hypertrophied 
vesicle,  which,  without  sexual  in- 
tercourse, would  have  remained 
intact  for  several  days  longer. 
However,  it  may  be  admitted,  as 
a  general  rule,  that  the  rupture 
occurs  during  the  last  days  of  the 
flow. 

The   series   of  phenomena   of 
which  the  ovary  is  the  seat,  is  not 
terminated  by  the  rupture  of  the 
vesicle,  and  it  remains  for  us  to 
state  what  becomes  of  its  walls  after  the  expulsion  of  the  ovule. 

Of  the  Corpora  Lutea. — Immediately  after  the  rupture  of  the  Graafian 
vesicle  and  the  consequent  expulsion  of  the  ovule,  an  effusion  of  blood, 
according  to  some,  and  of  plastic  lymph,  according  to  others,  takes  place 
into  the  emptied  cavity;  moreover,  the  walls,  which  were  greatly  distended, 
retract  strongly  upon  the  effused  matter,  and  form  with  it  a  more  or  less 
compact  mass,  which  after  a  time  assumes  an  orange-yellow  color.  From 
this  latter  circumstance,  the  tumor  has  acquired  the  name  of  the  yellow 
body,  or  corpus  luteuin. 

Although  for  a  long  time  considered  by  nearly  every  author  as  an  ir- 
refragable proof  of  a  previous  conception,  it  is  at  present  well  known  that 


IJt<TU8  laid  open,  so  as  to  exhibit  the  Hypertrophy  of  the 
Mucous  Membrane  at  the  Menstrual  Period. 
a.  Mucous  membrane  of  the  neck.  b.  Mucous  mem- 
btane  of  the  body,  much  swollen,  c.  Thickness  of  the 
section  of  the  mucous  membrane,  p.  Tissue  proper  of 
(be  litems,  e,  r.  Diminution  in  the  thickness  of  the  nm- 
ii. ns  membrane  at  the  neck  and  at  the  orifices  of  the  Fal- 
ii'lii.m  tubes. 


OVULATION     AND     MENSTRUATION. 


97 


this  body  may  exist  in  a  virgin  girl,  provided  she  has  previously  men- 
struated. 

Very  different  opinions  have  been  promulgated  as  to  the  mode  of  forma- 
tion of  the  yellow  body,  as  also  in  regard  to  the  precise  period  at  which  it 
commences.  According  to  Robert  Lee,  the  mass  of  this  body  is  formed 
exteriorly,  around  the  empty  capsule  of  the  vesicle,  and  consequently  it 
has  intimate  connections  with  the  ovarian  stroma;  but  this  opinion  is  inad- 
missible. 

From  the  observations  of  Baer  and  Valentin,  the  yellow  body  results 
from  the  hypertrophy,  or  a  kind  of  puffing  up,  of  the  membrane  of  the 
vesicle,  which  throws  out  a  species  of  vascular  processes  that  serve  to  fill 
up  the  whole  cavity  of  the  follicle,  excepting  at  the  part  occupied  by  the 
ovule.  In  the  latter  view,  as  well  as  in  that  entertained  by  Montgomery, 
the  development  of  the  corpus  luteum  will  aid  in  rupturing  the  vesicle,  by 
the  distention  it  produces,  and  will  soon  after  determine  the  expulsion  of 
the  ovule,  by  pressing  it  gradually  towards  the  thinnest  part. 

Both  suppose  that  the  corpus  luteum  is  completely  developed  when  the 
vesicular  rupture  and  the  discharge  of  the  ovule  take  place,  which,  how- 
ever, appears  altogether  inadmissible  to  me.  I  am  convinced  to  the  con- 
trary, from  the  specimens  which  M.  Raciborsky  has  had  the  kindness  to 
show  me.  In  a  female,  who  died  during  menstruation,  I  was  enabled  to 
prove  the  recent  rupture  of  a  vesicle  that  was  very  much  hypertrophied ; 
its  cavity,  however,  did  not  contain  a  yellow  body.  This  does  not,  there- 
fore, precede  the  rupture  of  the  vesicle.  In  my  opinion,  M.  Raciborsky  has 
perfectly  described  the  phenomena,  consecutive  to  this  rupture,  in  the  interes- 
ting treatise  published  by  him  {De  la  Ponte  Periodique  chez  les  Femmes  et  lei 
Mammijeres,  1844).     It  may  prove  useful  to  publish  his  views  in  this  work. 

"  If  the  ovaries  be  examined  eight,  ten,  or  twelve  days  after  the  cessation 
of  the  menstrual  discharge,  a  small,  rounded  tumefaction,  surmounted  by  a 
red  spot  like  an  ecchymosis,  and  presenting  in  its  centre  a  slight  linear 
fissure,  will  be  found  on  the  surface  of  one  of  these  organs.  The  margins 
of  the  fissure  are  agglutinated,  even  this  early,  in  the  majority  of  cases,  but 
it  is  still  easy  to  separate  them  by  using  lateral  tractions.  If  the  ovary  be 
then  opened  at  the  ecchymosed  spot,  the  interior 
will  exhibit  a  pouch,  already  smaller  than  the 
cavity  of  the  vesicle  before  the  rupture,  but 
entirely  filled  by  a  clot  of  blood,  which,  when 
placed  in  alcohol,  has  the  consistence  of  a 
solid  body,  though  somewhat  spongy  in  its 
nature.  The  clot  is  usually  about  the  size  of  a 
medium  cherry  (see  Fig.  34),  and  may  be  raised 
from  its  cavity  without  difficulty.  The  pari- 
etes  of  the  vesicle  exhibit,  at  this  period,  a 
yellowish  hue,  that  disappears  in  spirits  of  wine. 
The  surface  of  the  membrane  is  at  once  slightly 
plaited  and  downy.  In  the  meanwhile,  the 
most  soluble  molecules  of  the  clot  are  absorbed,       The  ov;(r-v  ,aM  "i""n  longitudinally, 

,      .  „        ,  ,  „  .  and  Knowing  the  corpu?  luteum  at  * 

and  then  a  further  retraction  of  the  tunic  takes     certain  singe  of  iu  development. 


FlO.  36. 


98  FEMALE  ORGANS  OF  GENERATION. 

place.  Being  continually  forced  to  follow  the  diminution  of  the  clot,  and 
to  become  moulded  upon  it,  it  forms  anew  a  certain  number  of  folds,  which 
finally  adhere  to  each  other,  and  thus  diminish  the  surface  of  the  mem- 
brane. Afterwards,  a  new  absorption  of  soluble  parts,  a  further  retractioD 
of  the  tunics,  a  fresh  diminution  of  the  cavity,  &c,  &c.  "Whence,  at  the 
end  of  a  month,  the  only  remnant  of  the  pouch,  that  could  once  have  con- 
tained a  small  cherry,  is  but  a  little  spot,  that  would  hardly  inclose  its 
stone."     (See  Fig.  36.) 

The  tunic  of  the  vesicle  becomes  hypertrophied  whilst  undergoing  the 
forced  plaiting,  caused  by  the  incessant  retraction  of  the  peripheral  fibres, 
thus  constituting  a  radiated  mass,  which,  from  the  imbibition  of  the 
coloring  principles  of  the  blood,  assumes  a  very  characteristic  orange-yellow 
color. 

This  coloration  is  not  produced,  as  M.  Montgomery  and  several  others 
supposed,  from  the  deposit  of  a  substance  of  a  new  formation,  either  exter- 
nally to,  or  within  the  vesicle,  or  between  the  two  tunics  that  constitute  its 
walls,  but  is  simply  the  result  of  imbibition.  Finally,  the  absorption  of  the 
clot  being  complete,  the  two  opposed  walls  of  the  pouch,  in  time,  approach 
each  other,  and  thenceforth  form  merely  a  single  slate-colored  line.  The 
vesicular  cavities  are  reduced  to  this  condition  in  from  four  to  six  months. 

Both  M.  Coste  and  M.  Raciborsky  acknowledge  the  folding  of  the  mem- 
brane of  the  vesicle,  but  the  theory  of  the  former  in  relation  to  it  differs  so 
much  from  that  of  the  latter  as  to  make  it  our  duty  to  explain  it  briefly. 

Immediately  after  its  rupture,  the  ovarian  follicle  becomes  filled  with  a 
gelatiniform  matter,  which  often  receives  a  red  color  from  the  blood  which 
escapes  from  a  few  opened  vessels ;  the  matter  itself  assumes  at  a  later 
period  a  greater  consistency.  By  the  spontaneous  retraction  of  the  walls, 
as  we  have  already  explained,  they  are  promptly  thrown  into  folds,  and 
the  rugae  which  result  from  retraction  are  so  numerous,  so  prominent,  and 
so  compact,  as  to  bear  some  resemblance  to  the  circumvolution  of  the  brain. 
(See  Fig.  37.)  Contemporaneously  with  this  folding,  the  wall  becomes 
hypertrophied  and  inflamed  ;  it  assumes  a  red  color,  and  encroaches  more 
and  more  upon  the  cavity  which  it  finally  fills,  just  as  though  it  had  given 
rise  to  granulations.  Ere  long,  however,  the  plastic  matter  which  at  first 
filled  the  follicle,  having  been  gradually  absorbed,  the  juxtaposed  circum- 
volutions contract  intimate  adhesions  with  each  other,  and  the  replete  follicle 
forms  a  large  tumor  upon  the  surface  of  the  ovary. 

Long  before  the  folds  or  circumvolutions  which  tend  to  fill  up  the  cavity 
of  the  ruptured  follicle  are  so  tumefied  as  to  come  in  contact,  their  tissue 
loses  the  inflammatory  redness  which  it  at  first  possessed.  But  as  M. 
Coste  does  not  recognize  the  formation  of  a  clot  of  blood  in  the  vesicular 
cavity,  he  cannot  admit  with  M.  Raciborsky  that  the  yellow  hue  of  the 
mass  just  described  is  due  to  the  imbibition  of  its  coloring  matter.  On  the 
contrary,  he  considers  the  color  to  be  due  simply  to  the  nature  of  the 
molecular  granules  which  enter  into  the  structure  of  the  internal  layer. 
These  granules,  he  says,  are  remarkable  not  only  from  their  number,  but 
..n  accounl  of  their  light  yellow  hue.  Therefore, as  after  the  folding  of  the 
internal  tunic,  they  are   both  very  numerous  and  very  compactly  bestowed, 


OVULATION     AND    MENSTRUATION.  99 

the  )ellow  tinge,  which  is  very  light  for  each  taken  separately,  becomes 
deep  for  the  entire  mass. 

The  two  opinions  may  therefore  be  recapitulated  thus  :  1.  Effusion  of  a 
coagulable  fluid,  which  is  blood,  according  to  M.  Raciborsky,  and  plastic 
lymph,  according  to  M.  Coste.  2.  Folding,  and  progressive  hypertrophy 
of  the  wall  of  the  vesicle.  3.  Yellow  coloration  of  the  latter,  either  by  the 
coloring  matter  of  the  blood  (Raciborsky),  or  by  the  condensation  of  the 
molecular  granules  (Coste).  These  two  theories,  which  include  nearly  all 
the  others,  yet  differ  upon  an  important  point.  According  to  MM.  Raci- 
borsky, Pouchet,  Dalton,  &c,  there  is  at  first  an  effusion  of  fluid  blood, 
which  soon  forms  a  clot  of  greater  or  less  density  ;  M.  Coste,  on  the  contrary, 
regards  this  effusion  of  blood  as  pathological,  or,  at  most,  as  an  exceptional 
occurrence. 

[Most  physiologists  now  think  that  after  its  rupture,  the  cavity  of  the  Graafian 
vesicle  becomes  filled  with  a  plastic  secretion  sometimes  tinged  with  blood  ;  the 
formation  of  a  clot  being  an  exceptional  occurrence.  While  this  secretion  is  beinu; 
formed,  the  muscular  fibres  of  the  stroma  retract  and  compress  the  wall  of  the 
ovisac,  which  not  being  retractile,  is  thrown  into  folds,  as  has  been  said.  Some  of 
the  cells  of  the  granular  membrane  which  remain  adherent  to  the  internal  surface 
of  the  ovary  undergo  hypertrophy,  and  fatty  granules  are  produced  which  give 
a  yellow  color  to  the  tumor.  The  folds  project  more  and  more  and  finally  become 
adherent.  Then,  after  having  remained  stationary  for  a  certain  time,  this  corpus 
luteum  becomes  atrophied  and  gives  place  to  a  depressed  cicatrix.  In  short,  M. 
Coste's  theory  would  seem  to  be  the  true  one,  whilst  the  phenomena  described  by 
Raciborsky,  though  real,  are  exceptional  and  pathological.] 

"Whatever  be  the  fate  of  the  ovule  after  its  expulsion,  whether  it  receives, 
or  not,  the  vivifying  influence  of  the  seminal  fluid,  the  remains  of  the  torn 
capsule  always  undergo  the  primary  changes  described  above. 

As  the  formation  of  corpora  lutea  always  follows  the  rupture  of  a  Graafian 
vesicle,  and  as  this  rupture  is  most  frequently  spontaneous,  it  is  evident  that 
medical  jurists  have  committed  an  error  in  regarding  their  existence  in  the 
ovary  as  a  certain  indication  of  an  anterior  fecundation  ;  but  some  modern 
physiologists  have  also  been  wrong  in  supposing  that  the  study  of  the 
corpora  lutea  could  have  no  medico-legal  importance  whatever;  for, 
although  the  supervention  of  pregnancy  modifies  the  corpora  lutea  in  no 
respect  at  the  commencement  of  their  formation,  it  exercises  an  incontestable 
influence  upon  their  ulterior  development.  M.  Coste,  who  has  followed 
their  evolution  step  by  step  in  the  two  cases,  has  derived  from  his  attentive 
observation  sufficient  means  of  distinguishing  a  corpus  luteum  succeeding 
to  a  pregnancy,  from  one  pertaining  to  a  female  who  has  not  conceived. 

Not  less  than  a  month,  says  he,  is  required  in  a  pregnant  woman  for  the 
filling  up  of  the  follicle,  and  the  commencement  of  adhesion  between  the 
folds;  and  forty  days,  nearly,  will  have  elapsed,  before  the  connections  are 
firmly  established.  At  this  time,  their  assemblage  forms  a  compact  and 
resisting  tumor,  of  nearly  an  inch  in  its  longest  diameter,  and  five-eighths 
of  an  inch  in  its  shortest.  Having  thus  arrived  at  its  maximum,  it  remains 
stationary  for  some  time,  until  toward  the  end  of  the  third  month  its  period 
of  diminution  commences.     The   tumor  is   gradually  absorbed.    Iosps    it* 


100 


FEMALE  ORGANS  OF  GENERATION". 


volume,  and  seems  to  enter  again  into  the  organ  upon  the  surface  of  which 
it  had  heen  raised  ;  at  the  same  time  it  becomes  more  compact,  denser,  and 
more  shining.  In  the  course  of  the  fourth  month  it  is  nearly  one-third, 
and  towards  the  end  of  the  fifth,  nearly  one-half  smaller.  From  the 
sixth  to  the  ninth  month  it  will  have  lost  nearly  two-thirds  of  its  volume; 
still,  however,  it  forms  after  labor  a  tubercle  of  not  less  than  five-sixteenths 
of  an  inch  in  diameter.  The  latter  now  diminishes  with  considerable 
rapidity,  but  nearly  a  month  is  required  for  its  reduction  to  a  small  and 
hard  nucleus  of  indefinite  duration.  There  is  nothing  absolute,  however, 
in  the  rate  of  retrogression  of  this  phenomenon.  For,  as  in  some  women 
who  died  between  the  sixth  and  eighth  month  of  their  pregnancy,  the 
corpora  lutea  were  found  as  voluminous  as  in  others  at  the  fourth  month, 
*o  evident  traces  of  it  may  sometimes  be  discovered  several  months  after 
labor. 

When  the  corpus  luteum  is  produced  under  other  influences  than  those 
to  which  impregnation  gives  rise,  its  development,  adds  M.  Coste,  is  by  no 
means  so  great,  and  its  rate  of  diminution  is  more  rapid.  Whilst,  for 
example,  from  five  to  six  months  are  required  for  the  completion  of  the 
chief  modifications  during  pregnancy,  the  capsules  are  almost  entirely 
effaced  in  from  twenty-five  to  thirty  days,  in  women  who  have  not  been 

Fio.  37. 


Represents  a  corpus  luteum  derived  from  a  female  who  died  in  the  sixth  month  of  pregnancy. 

tinpregnated.  The  phenomena  presented  at  the  commencement,  in  the  last 
case,  are  the  same  as  in  the  former,  but  the  vesicles  suddenly  soften,  and 
are  frequently  entirely  absorbed  before  the  circumvolutions  of  the  internal 
layer  have  acquired  sufficient  development  to  come  in  contact,  or  to  con- 
tract adhesions.  M.  Coste  has  never  known  the  corpora  lutea  of  a  non- 
pregnant female,  who  had  died  suddenly,  to  resemble  those  observed  in  the 
second  or  third  month  of  pregnancy ;  they  have  neither  the  size  nor  the 
density  of  the  latter  (Fig.  37).  In  a  word,  adds  the  learned  embrvologist, 
a  corpus  luteum  which  is  as  large  as  the  ovary  itself,  which  forms  a  solid 
and  resisting  tumor,  exhibiting  upon  section  the  capsule  of  the  ruptured 
vesicle   filled  with    the  stronsrh'-adherent   internal  circumvolutions,  must 


OVULATION     AND     MENSTRUATION.  101 

belong  to  a  pregnant  female.  If  the  circumvolutions  are  but  feebly  united, 
having  between  them  a  layer  of  plastic  matter  which  serves  as  a  medium 
of  adhesion,  the  corpus  luteum  corresponds  to  the  second  month  of  preg- 
nancy ;  if,  on  the  contrary,  the  circumvolutions  are  blended  into  a  compact 
mass,  preserving  at  the  same  time  a  size  similar  to  the  preceding,  it  may  be 
regarded  as  derived  from  a  woman  who  had  died  toward  the  end  of  the 
third  month  of  gestation. 

From  this  time  the  mass  becomes  more  and  more  compact,  remains  station- 
ary for  a  while,  and  then  tends  to  decrease  until  the  end  of  gestation. 

To  explain  the  passage  of  the  ovule  into  the  Fallopian  tube,  Rouget  has 
shown  that  a  double  layer  of  muscular  fibres  passes  from  the  lumbar  region 
of  the  uterus  and  embraces  the  whole  extent  of  the  tube  and  fimbriated 
extremity.  By  its  contraction  during  sexual  intercourse  the  tube  is  flexed 
upon  itself  and  the  fimbriated  extremity  is  drawn  toward  and  is  applied  to 
the  surface  of  the  ovary.  While,  as  has  been  shown,  coitus  hastens  the 
rupture  of  ripe  follicles,  the  fact  remains  that  the  ovule  may  be  discharged 
at  any  time,  before,  during,  or  after  the  menstrual  flow. 

A  more  plausible  theory  is  that  the  cilia  covering  the  mucous  membrane 
of  the  fimbriae  directs  the  current  of  liquid  bathing  the  ovaries  toward  the 
tube,  and  the  ovule  is  thus  made  to  enter. 

In  exceptional  cases  the  ovule  fails  to  enter  the  Fallopian  tube,  and  may 

be  developed  within  the  peritoneal  cavity,  giving  rise  to  the  condition  known 

as  extra-uterine  pregnancy. 

"  Schroeder  has  collected  from  various  authors  the  reports  of  several  cases  in 
which  an  ovum  has  been  discharged,  has  found  its  way  into  the  uterus,  and  has  under, 
gone  development,  one  tube  being  closed  and  the  corpus  luteum  existing  upon  the 
side  on  which  the  tube  was  impervious.  In  some  instances  in  which  the  corpus 
luteum  has  been  found  on  the  side  on  which  the  tube  was  closed,  tubal  pregnancy  has 
occurred  upon  the  opposite  side.  In  these  cases  the  ovum  must  have  passed  across  the 
uterus."     (Flint's  Phys.,  page  873.) 

In  reviewing  the  facts  whose  history  we  have  just  traced,  we  see  that 
towards  the  age  of  puberty,  the  ovary  becomes  the  seat  of  an  active  conges- 
tion, and,  it  might  be  said,  of  a  new  vitality  ;  all  the  living  powers  of  the 
organ  seem  to  be  concentrated  upon  one  of  the  Graafian  vesicles,  which  sud- 
denly assumes  a  considerable  development,  and  in  so  doing,  raises  the 
envelope  of  the  ovary,  and  forms  a  tumor,  which  is  superadded  to  the  organ. 
The  walls  of  the  vesicle  become  weaker  and  weaker  as  their  distention 
increases,  until  they  finally  give  way ;  in  consequence  of  the  rupture,  the 
ovule  is  expelled  and  carries  with  it  a  portion  of  the  granular  fluid  with 
which  it  was  surrounded.  This  expulsion  constitutes  the  phenomenon 
known  of  latter  time  as  spontaneous  ovulation.  The  void  left  in  the  vesicle 
is  soon  filled  with  blood  and  a  gelatinous  matter,  which  is  secreted  by  the 
walls  of  the  follicle ;  the  latter  becomes  hypertrophied  and  thrown  into  folds 
by  the  retraction  of  the  external  tunic,  and  soon  constitutes  the  corpus 
luteum. 

As  accessory  phenomena,  it  is  known  that  the  uterus  and  its  annexes  par- 
ticipate to  a  greater  or  less  degree  in  the  ovarian  activity,  and  we  have 
briefly  described  the  peculiarities  which  they  present  during  the  accomplish- 
ment of  the  process;  we  shall  have  occasion  to  return  to  it  in  future.  Our 
attention  should,  however,  he  first  directed  to  the  great  resemblance  between 


102  FEMALE     ORGANS     OF     GENERATION. 

this  succession  of  physiological  acts,  and  the  series  of  phenomena  which 
comparative  physiology  and  anatomy  have  shown  to  take  place  in  mamma- 
lia at  the  rutting  season.  In  them  likewise,  the  approach  of  the  male  is 
not  necessary  to  the  discharge  of  the  ovule,  and  the  spontaneous  ovulation 
is  accompanied  with  almost  identical  changes  in  the  genital  organs,  and 
manifests  its  influence  upon  the  entire  organism  by  the  same  assemblage  of 
phenomena.  In  the  human  female,  as  in  the  mammalia  and  birds,  the 
spontaneous  ovulation,  accompanied  with  the  same  cortege  of  symptoms. 
ch  ars  at  more  or  less  regular  intervals.  In  the  rabbit,  it  is  the  tume- 
faction and  almost  varicose  injection  of  the  vessels  of  the  vulva.  To  this 
coloring  and  tumefaction  is  added,  in  the  bitch,  an  odorous  secretion,  which 
allures  the  males,  and  puts  them  upon  the  track  of  the  females.  Finally,  in 
monkeys,  a  more  or  less  abundant  hemorrhage  occurs,  which,  in  the  case  of 
the  niacaquas  and  the  cynocephalre,  coincides  with  so  monstrous  a  swelling 
of  the  vulva,  that,  in  certain  cases,  the  surrounding  parts  are  infiltrated  as 
though  inflamed  in  consequence  of  the  sting  of  bees.  We  shall  study  here- 
after the  peculiarities  of  these  returns  in  the  human  species. 

The  vesicular  evolution,  accompanied  with  the  array  of  phenomena  just 
described,  is  reproduced  at  intervals  which  vary  for  different  animals,  but 
in  the  human  female  recurs  at  much  shorter  periods.  Every  month,  in  fact, 
in  the  normal  condition,  a  new  Graafian  vesicle  is  found  to  increase  in  size, 
to  become  excessively  distended,  and  finally  bursting  and  discharging  the 
ovule,  to  become  the  seat  of  the  successive  transformations  presented  by  the 
corpus  luteum.  Every  month,  therefore,  this  curious  phenomenon  of  spon- 
taneous ovulation  is  renewed  ;  ana  the  dark-colored  cicatriculcs  of  various 
form,  which  are  observed  upon  the  surface  of  the  ovary  of  nubile  women, 
give  rise  to  the  supposition  exclusive  of  direct  observation,  that  the  opera- 
tion of  which  they  are  the  consequence  must  have  recurred  a  great  number 
of  times. 

Of  the  phenomena  which  we  have  just  described,  the  flow  of  blood  had, 
until  of  late  years,  chiefly  claimed  attention.  This  flow,  as  well  as  the  vesi- 
cular evolution  of  which  it.  is  the  consequence,  occurs  for  the  first  time 
between  the  ages  of  twelve  and  fifteen  years,  and  is  afterward  periodically 
renewed  every  month  until  the  time  of  life  at  which  the  female  loses  her 
aptitude  for  fecundation,  that  is  to  say,  until  she  attains  the  age  of  from 
forty-five  to  fifty  years.  Known  under  the  names  of  the  monthly  sickness, 
the  monthlies,  courses,  &c,  this  periodical  excretion  constitutes  menstruation ; 
a  phenomenon  which,  though  doubtless  of  importance,  is  nevertheless  ihr 
from  being  the  capital  fact  amongst  those  which  we  have  studied,  for  it  may 
be  absent,  without  the  vesicular  changes  being  notably  affected  thereby, 
whilst,  on  the  other  hand,  it  never  appears  without  having  been  preceded 
and  accompanied  by  the  development  of  a  Graafian  vesicle.  It  is  therefore 
a  secondary  phenomenon  intimately  connected  with  those  which  are  accom- 
plished in  the  ovary.  The  details  into  which  we  are  about  to  enter,  in 
reference  to  menstiuation,  will  complete  the  history  of  the  ovarian  follicles 


OVULATION   AND   MENSTRUATION.  103 

ARTICLE    II. 

OF   MENSTRUATION. 

Menstruation  is,  as  we  have  said,  a  periodical  flow  of  bU  od  from  the 
genital  parts,  having  its  source  in  the  walls  of  the  uterus.  Its  first  appear- 
ance, which  is  always  determined  by  the  ovarian  evolution  of  which  it  is 
me  of  the  epiphenomena,  reveals  the  aptitude  of  the  female  for  fecundation, 
and  constitutes  one  of  the  earliest  signs  of  puberty  or  nubility;  I  say  one  of 
the  earliest  signs,  for  it  very  rarely  occurs  suddenly,  and  without  having 
been  preceded  by  precursory  phenomena. 

These  phenomena  are  both  local  and  general.  The  first,  which  are 
purely  physical,  occur  more  especially  in  the  generative  organs.  Thus,  the 
pubic  region  becomes  covered  with  hair ;  the  pelvis,  which  hitherto  differed 
but  slightly  from  that  of  the  male,  increases  in  size  in  every  direction,  and 
gradually  assumes  the  shape  which  we  have  indicated  as  peculiar  to  the 
well-formed  woman ;  the  breasts  are  rapidly  developed,  and  the  nipple  is 
more  projecting,  tui'gescent,  and  sensitive ;  the  skin  which  surrounds  the 
latter  is  also  of  a  darker  color  than  before.  The  outlines  of  the  body  at 
the  same  time  become  rounded,  in  consequence  of  the  greater  abundance 
and  more  harmonious  distribution  of  the  cellulo-fatty  tissue. 

These  physical  changes  are  rarely  found  unconnected  with  an  alteration 
in  the  moral  state  of  the  young  girl.  Her  voice  assumes  a  softer  tone,  her 
looks  are  more  timid,  and  often  embarrassed  in  the  presence  of  persons  with 
whom  but  a  few  months  previously  she  had  sported  as  a  child.  She 
experiences  desires,  which  are  the  vague  expressions  of  the  development  of 
the  senses,  which  she  cannot  yet  understand.  A  melancholy  sadness,  and  a 
taste  for  solitary  places  congenial  t©  reverie,  replace  the  boisterous  pleasures 
of  childhood. 

The  congestion  which  precedes  the  hemorrhage  is  indicated  by  new 
symptoms.  The  young  girl  complains  of  lassitude,  of  a  sensation  of  swell- 
ing and  tension  in  the  lower  part  of  the  abdomen,  of  lumbar  and  sacral 
pains,  of  weight  in  the  loins,  of  heat  in  the  hypogastrium  and  peritoneum, 
of  a  slight  itching  and  tumefaction  in  the  genital  parts,  and  a  painful  swell- 
ing of  the  breasts.  In  many  cases,  the  excitement  of  the  genital  organs  is 
so  great  as  to  produce  a  violent  general  reaction ;  and,  according  to  Boer- 
haave,  the  first  appearance  of  the  menses  is  accompanied  with  fever. 
Strange  nervous  disturbances  not  unfrequently  occur,  and  I  have  sometimes 
observed  attacks  of  genuine  hysteria.  These  symptoms  may  last  from  one 
to  eight  days,  and  are  followed  by  a  more  or  less  abundant  flow  of  mucus ; 
in  the  course  of  a  few  days,  this  becomes  mixed  with  a  little  blood,  and 
soon  gives  place  to  a  flow  of  almost  pure  blood.  The  hemorrhage  continues 
for  several  days ;  then,  as  the  amount  of  blood  mingled  with  the  vaginal 
mucosities  diminishes,  the  flow  becomes  less  colored,  and  after  resuming  the 
characters  of  the  vaginal  secretions,  ceases  entirely. 

Quite  frequently,  the  first  menstruation  takes  place  without  having  been 
preceded  by  any  of  these  discomforts.  Sometimes  the  eruption  of  blood 
occurs  whilst  playing  or  dancing,  and  sometimes  during  sleep. 

In  most  young  girls  the  eruption  returns  after  the  lapse  of  a  month,  and 


104  FEMALE     ORGANS     OF     GENERATION. 

follows  subsequently  its  regular  periodical  course;  frequently,  however,  it 
is  not  until  after  three  or  four  periods,  and  sometimes  even  later,  that  the 
courses  become  regular.  In  other  cases,  again,  a  long  interval  elapses 
between  the  two  first  menstruations :  thus,  M.  Raciborsky,  having  noticed 
the  time  between  the  two  first  menstrual  periods  in  eighty-seven  females, 
found  that  in  all  but  fifty-eight,  more  than  a  month  elapsed  between  them. 
In  two  women,  the  second  menstruation  occurred  six  weeks  after  the  first; 
in  four,  two  months ;  in  five,  three  months ;  in  four,  four  months ;  in  one, 
five  months;  in  one,  eight  months;  in  three,  a  year;  finally,  in  one,  two 
years. 

These  irregularities  in  the  return  of  the  second  period  may,  doubtless,  be 
due  to  a  morbid  condition  requiring  treatment,  but  they  may  also  depend 
upon  an  atony  of  the  genital  organs,  which  does  not  allow  the  physiological 
development  of  the  Graafian  vesicles  to  continue.  This  temporary  atony 
does  not  interfere  with  the  general  health  of  the  female,  nor  prevent  the 
future  performance  of  the  function  ;  it  often  disappears  under  the  excite- 
ment produced  by  a  change  of  life,  or  by  the  first  conjugal  approaches. 
(Raciborsky.) 

In  some  young  girls,  the  functional  troubles  and  abdominal  pains,  which 
we  have  regarded  as  so  many  precursory  phenomena  of  the  first  appearance 
of  the  menses,  may  not  be  followed  by  the  flow  of  blood,  and,  after  having 
lasted  for  several  days,  they  diminish  and  cease  entirely;  they  may  recur 
thus  every  month,  for  a  certain  time,  with  no  other  result  than  a  momentary 
disturbance  of  the  general  health,  and  it  is  only,  so  to  speak,  after  several 
fruitless  attempts,  that  the  courses  become  established  in  a  complete  and 
regular  manner. 

The  symptoms  which  heralded  the  first  menstrual  flow  do  not  usually 
recur  at  the  subsequent  periods,  or,  at  least,  they  continue  to  diminish  with 
each  monthly  return.  In  some  females,  however,  they  always  appear  with 
their  original  intensity,  and  I  have  often  remarked,  in  reference  to  these 
cases,  that  the  acute  pains  and  colics  which  prelude  the  flow  of  blood, 
disappear,  or  even  cease  entirely,  immediately  after  the  first  conjugal 
approaches,  and  especially  after  the  first  labor.  In  a  still  greater  number, 
the  return  of  the  menstrual  period  is  throughout  life  indicated  by  some 
Blight  pains,  a  little  uneasiness,  or  merely  by  a  more  or  less  marked  dis- 
turbance of  the  general  condition;  the  temper  is  less  even,  the  woman 
becomes  more  excitable,  more  irascible,  in  a  word,  less  amiable. 

The  time  at  which  the  first  appearance  of  the  menses  occurs  varies  exceed- 
ingly from  the  influence  of  climate,  habits  of  life,  and  constitution.  The 
following  table,  extracted  from  the  work  of  Midler,  with  notes  by  Jourdan, 
gives  an  idea  of  these  variations  in  different  countries. 


OVULATION   AND   MENSTRUATION. 


105 


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4 

4 

13 

14 

20 

13 

13 

6 

8 

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1 

6  years, 

7  " 

8  « 

9  " 

10  " 

11  " 

12  •« 

13  " 

14  " 

15  « 

16  " 

17  " 

18  « 

19  " 

20  " 

21  " 

22  " 

23  «' 

24  " 

25  " 

1 
1 

2 

11 

29 

96 

129 

138 

212 

204 

140 

133 

95 

43 

33 

8 

8 

4 

5 

14 

26 

47 

50 

76 

79 

58 

38 

21 

9 

5 

1 

5 

6 

10 
13 
9 
16 
8 
4 
2 

10 
19 
63 
85 
97 
76 
57 
26 
23 
4 

3 

8 

21 

32 

24 

11 

18 

.  10 

8 

1 

1 

4 
10 
20 
20 
38 
41 
20 
20 
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4 
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18 
34 
40 
55 
77 
81 
72 
35 
26 
24 
14 

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15 
27 
35 
13 
6 
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Total,    .  . 

1285 

342 

68 

450 

137 

200 

487 

100 

100 

i 

According  to  this  table,  the  greater  number  of  first  menstruations  occur, 
at  Paris,  between  the  ages  of  fourteen  and  fifteen  years ;  but  it  may  be 
remarked,  that  the  most  common  variations  fall  between  the  ages  of  eleven 
or  twelve,  and  seventeen  or  eighteen  years. 

Warm  climates,  a  residence  in  cities  and  the  habits  which  are  contracted 
there,  together  with  robust  constitutions,  seem  to  favor  the  precocious 
development  of  puberty ;  a  low  temperature,  residence  in  the  country,  a 
feeble  and  delicate  constitution,  appear,  on  the  other  hand,  to  retard  the 
appearance  of  the  menses. 

Numerous  exceptions  to  the  averages  above  indicated  are  mentioned  by 
authors.  Thus,  as  examples  of  tardy  and  precocious  menstruation,  we  see 
by  the  table  that  five  women  menstruated  for  the  first  time  at  the  age  oi 
twenty-three  years,  six  at  twenty-four,  and  two  at  twenty-five.  In  some 
very  rare  instances,  the  first  appearance  has  been  delayed  for  a  much  longer 
time ;  thus,  M.  Kleeman  mentions  the  case  of  a  woman  who  was  married  at 
the  age  of  twenty-seven  years,  and  who  did  not  menstruate  until  two  months 
after  her  eighth  confinement;  she  then  continued  regular  until  the  age  of 
fifty-four  years.  Pecklin  speaks  of  a  strong  and  healthy  married  woman,, 
who  had  never  menstruated,  although  she  was  forty  years  of  age ;  her 
courses  made  their  appearance  upon  one  of  the  first  nights  succeeding  her 
second  marriage,  and  recurred  regularly  for  two  years,  at  the  expiration  of 
which  time  she  became  pregnant. 

If  we  compare  these  cases  of  tardy  menstruation  with  the  nume  ous 
instances  of  women  who  become  mothers  without  ever  having  menstruated, 
aud  of  nurses  in  whom  the  suppression  of  the  menses  did  not  prevent  con- 


106  FEMALE  ORGANS  OF  GENERATION. 

ception,  we  shall  find  a  full  confirmation  of  what  was  stated  in  the  preceding 
chapter,  in  relation  to  the  secondary  importance  of  the  menstrual  discharge. 
Regarded  as  a  phenomenon  attendant  upon  the  changes  going  on  in  the 
ovary,  it  may  be  absent  even  though  the  Graafian  vesicle  should  undergo 
all  its  phases  of  development;  nor  can  its  absence  be  now  considered  as 
indicative  of  the  impossibility  of  fecundation. 

We  cannot  accept  all  the  observations  of  very  precocious  menstruation  ; 
but,  laying  aside  the  numerous  cases  in  which  the  nature  of  the  discharge 
has  not  been  so  well  determined  as  to  allow  of  their  reception  without  ques- 
tioning, there  are  some  whose  genuineness  is  undoubted,  inasmuch  as  the 
appearance  of  the  discharge  was  attended  with  all  the  attributes  of  puberty. 
Thus,  Dr.  Susewind  knew  of  a  child  of  seventeen  months,  which  had  men- 
struated since  she  was  a  year  old ;  the  hemorrhage  returned  regularly  every 
month,  and  the  breasts  and  mons  veneris  were  those  of  a  girl  of  fourteen  or 
fifteen  years  of  age.  The  child  observed  by  Lenhossek  menstruated  when 
nine  months  old,  and  at  two  years  she  presented  all  the  external  signs  of 
puberty.  The  girl  mentioned  by  D'Outrepont,  who  had  four  teeth  when 
two  weeks  old,  was  regular  from  the  age  of  nine  months ;  she  had  at  that 
time  long  black  hair  and  prominent  breasts.  A  woman  observed  by  Carus, 
menstruated  when  two  years  old,  became  pregnant  at  eight,  and  died  at  an 
advanced  age. 

In  a  memoir  by  M.  Dezeimeris,  many  other  similar  facts,  derived  from 
Schcefer,  Louis  Robert,  Le  Beau,  Descuret,  Comarmond,  Clarke,  Lobstein, 
&c,  <fec,  are  recorded. 

These  premature  menstruations  are  certainly  due  to  the  same  causes 
which  determine  their  appearance  in  most  women  about  the  age  of  fifteen 
years.  Being  always  accompanied  by  the  development  of  the  breasts  and 
the  other  marks  of  puberty,  they  are  the  evidence,  that  under  the  influence 
of  an  anomalous  vitality  of  the  ovaries,  the  Graafian  vesicles  have  under- 
gone a  very  precocious  development. 

When  once  well  established,  the  menses  assume  their  regular  periodicity, 
which  is  generally  preserved  up  to  the  time  of  their  cessation,  without  other 
interruption  than  that  which  is  occasioned  by  nursing  or  pregnancy.  They 
return  about  every  month,  as  their  name  indicates ;  yet  the  interval  between 
them  is  far  from  being  the  same  for  every  female.  The  average  of  the 
catamenial  period  is  stated  by  Roser  and  Wunderlich  at  twenty-eight  days  ; 
in  a  large  number,  according  to  Brierre  de  Boismont,  it  is  thirty  days ;  and 
in  some  instances  the  intermenstrual  period  is  longer  than  thirty  days, 
extending  to  five  or  six  weeks,  and  sometimes  even  to  two  months.  In  some 
women  the  returns  occur  upon  the  same  day  of  each  month  ;  in  a  much 
greater  number,  the  end  of  the  solar  month  is  anticipated  by  two,  three, 
four,  or  five  days.  Sometimes  the  period  is  much  shorter,  the  returns  occur- 
ring at  an  interval  of  twenty-four,  twenty-two,  twenty,  and  even  fifteen  days. 

These  frequent  variations  in  the  duration  and  return  of  the  catamenial 
period  are  a  refutation  in  advance  of  the  opinion  of  those  authors  who 
think  that  all  women  menstruate  generally  at  the  same  periods,  and  that 
there  are  times  in  each  month  when  no  one  is  unwell ;  it  is  evident  that  the 
retardations  or  the  anticipations  of  which  we  have  spoken,  must  have  the 


OVULATION    AND    MENSTRUATION.  107 

effect  of  bringing  the  return  of  some  female  upon  every  day  of  the  year. 
The  flow  also  commences  almost  indifferently,  during  the  day  or  right. 

The  periodicity  of  the  catamenia  generally  continues  until  the  age  of 
from  forty  to  fifty  years,  at  which  time  they  usually  cease.  We  shall  here- 
after treat  of  the  peculiarities  which  often  attend  their  cessation. 

The  duration  of  the  flow  varies  between  one  and  eight  days ;  according 
to  Brierre,  it  most  commonly  lasts  for  eight  days ;  and  next  in  order  of 
frequency,  we  have  three,  four,  two,  five,  one,  six,  ten,  and  seven  days. 
Man)  observers  have  noted  three  or  four  days,  as  expressing  the  most 
usual  duration.  In  some  very  exceptional  cases,  it  lasts  for  a  few  hours 
only ;  in  others  quite  as  rare,  apart  from  pathological  conditions,  it  is  pro- 
longed through  twelve  or  fifteen  days. 

The  quantity  of  blood  lost  is  variable  for  the  same  woman,  and  especially 
bo  when  observed  in  different  individuals ;  we  may  here  add,  that  it  is  very 
difficult  in  any  case  to  estimate  it  exactly.  If  the  two  cotyles  of  Hippo- 
crates be  eighteen  ounces  (550  grammes),  as  translated  by  Galen,  his  esti- 
mate (provided  Galen's  rendering  is  correct)  is  evidently  exaggerated,  at 
least  for  our  time  and  climate.  If  we  appreciate  the  amount  of  blood 
lost  by  the  quantity  of  stained  linen,  I  think  the  estimate  of  Haen,  who 
set  it  down  as  averaging  from  three  to  five  ounces,  will  be  found  to  .^omt 
nearest  the  truth. 

The  quantity  of  the  discharge  appears  to  be  greatly  influenced  by  the 
diet,  habits  of  life,  and  climate  ;  it  is  greater  with  rich  and  indolent  females 
who  use  a  succulent  diet,  than  with  those  who  are  placed  in  an  opposite 
condition.  According  to  most  authors,  very  warm  climates  exert  a  marked 
influence  upon  it,  and,  for  my  own  part,  I  am  acquainted  with  several 
ladies  who  menstruate  much  more  abundantly  in  summer  than  in  winter. 

It  is  said  that  women  from  the  country,  who  become  domestics  in  Paris, 
soon  find  their  courses  to  diminish,  and  sometimes  even  cease  entirely. 
Such  may  be  the  case  with  many  of  them,  but  it  is  due  chiefly  to  the  in- 
fluence upon  their  constitutions  of  the  want  of  fresh  air,  exposure  to  the 
sun,  and  of  the  exercise  to  which  they  had  been  accustomed  from  child- 
hood, rather  than  to  any  change  in  their  diet;  for,  in  general,  the  nourish- 
ment which  they  receive  from  their  employers  is  much  better  than  that 
with  which  they  were  obliged  to  content  themselves  in  their  own  families. 

The  amount  of  the  discharge  is  not  the  same  throughout  the  duration  of 
the  menstrual  period  ;  ordinarily,  it  flows  moderately  on  the  first  and  second 
days,  increases  on  the  third  and  fourth,  and  then  gradually  declines. 
Neither  is  the  discharge  always  continuous;  it  sometimes  diminishes  and 
even  stops  entirely  for  several  hours,  sometimes  for  one  or  two  days,  and 
afterwards  reappears  either  spontaneously  or  under  the  influence  of  a  walk 
or  a  ride.  Moral  emotions,  sometimes  the  process  of  digestion,  and,  above 
all,  the  action  of  cold,  may  determine  its  momentary  or  final  diminution 
or  suppression. 

The  seat  of  the  hemorrhage  and  the  nature  and  qualities  of  the  menstrual 
blood,  have  been  the  subject  of  very  different  opinions.  What  we  have 
already  said,  whilst  describing  the  changes  in  the  uterine  inuous  mem- 
brane, duilng  the  ovarian  evolution,  leaves  no  doubt  as  to  the  source  of  the 


108  FEMALE  ORGANS  OF  GENERATION. 

menstrual  fluid.  It  exudes,  manifestly,  through  microscopic  fissures  on  the 
internal  surface  of  the  mucous  membrane  of  the  uterus.  This  fact,  which 
is  placed  beyond  a  doubt  by  numerous  autopsies  of  women  who  died  during 
menstruation,  had  been  already  proved  by  the  accumulation  of  blood  in 
the  cavity  of  the  womb,  where  the  neck  was  imperforate,  and  by  the  touch, 
and  the  speculum,  whereby  it  has  been  both  felt,  and  seen  to  flow  from  the 
orifice  of  the  uterus. 

Certain  facts  have  been  adduced  in  order  to  prove  that,  in  some  cases, 
the  menstrual  blood  proceeds  from  the  vagina.  I  think  that  the  greater 
number  of  these  observations  have  been  either  badly  made,  or  wrongly 
interpreted.  I  do  not  deny  the  possibility  of  exhalations  of  blood  from 
the  walls  of  the  vagina ;  but  if  they  present  the  periodicity  of  the  menses, 
they  can  be  regarded  in  no  other  light  than  as  a  misplacement  of  the  latter. 
The  fact  related  in  the  note  below  appears  to  me  to  possess  great  interest 
in  reference  to  this  subject.1 

1  I  Lave  recently  (November,  1849)  seen,  in  connection  with  my  excellent  confrere. 
Dr.  Thirial,  a  young  girl,  twenty-one  years  of  age,  who  had  menstruated  only  twice 
and  for  three  days  at  a  time  ;  and  in  whose  case  the  hemorrhage  must  of  necessity 
have  had  its  origin  in  the  mucous  membrane  of  the  vagina. 

This  young  girl,  who  had  been  for  a  long  time  violently  in  love  with  an  officer, 
dually  yielded  herself  completely  to  his  wishes.  After  several  attempts,  renewed 
with  much  ardor,  but  which  each  time  proved  fruitless,  the  young  man  finally  dis- 
covered, and  acquainted  her  with  the  fact,  that  she  was  not  formed  like  other  women, 
and  advised  her  to  consult  a  physician.  She  applied  first  to  M.  Thirial,  who  solicited 
my  opinion.     A  very  careful  examination  enabled  me  to  ascertain  as  follows : 

The  countenance,  stature,  and  development  of  the  limbs  and  breasts,  differed  in  no 
respect  from  what  is  usual  in  young  girls  at  her  age.  Her  general  health  had  always 
been  good.  In  the  month  of  May  last,  her  courses  appeared  for  the  first  time,  and 
continued  three  days;  she  had,  however,  for  several  years  before,  experienced  symp 
toms  of  uterine  congestion.  In  the  month  of  July,  they  showed  themselves  again 
for  the  last  time.  The  attempts  of  her  lover  were  twice  followed  by  a  considerable 
flow  of  blood,  which  lasted  two  days,  but  she  attributed  it  much  rather  to  the  amorous 
violence  to  which  she  had  been  subjected  than  to  a  periodic  return  of  the  menses. 

The  mons  veneris  is  completely  destitute  of  the  hair  with  which  it  is  usually 
covered.  Upon  the  lateral  and  inferior  regions,  immediately  above  the  external 
orifice  of  the  inguinal  canal,  a  lumor  is  observed  on  each  side  which  elevates  the 
integuments.  The  tumor  has  the  size,  form,  and  consistence  of  an  ovary  or  testicle  ; 
it  is  but  slightly  painful ;  under  a  very  moderate  pressure  it  retreats  through  the 
inguinal  canal,  and  disappears  iu  the  abdomen,  but  as  soon  as  the  pressure  is  removed 
lroin  the  internal  orifice  of  the  canal,  it  reappears,  sometimes  spontaneously,  some- 
times on  the  slightest  movements,  or  the  least  effort  of  coughing  or  respiration.  On 
no  occasion  was  I  able  to  perceive  the  signs  which  ordinarily  accompany  the  reduc- 
tion of  an  intestinal  or  epiploic  hernia. 

The  vulvar  opening  was  bounded  by  the  greater  and  the  lesser  labia,  but  both  were 
much  less  developed  than  usual.  The  finger,  which  could  be  introduced  only  with 
difficulty  into  the  vulvar  orifice,  was  arrested  at  a  depth  of  three-quarters  of  an  inch, 
40  that  it  was  only  by  forcing  up  the  exireinity  of  the  vagina,  that  the  first  phalanx 
could  be  made  to  enter  that  canal. 

Upon  introducing  the  extremity  of  a  speculum,  it  was  impossible  to  discover  anj 
opening,  or  any  point  which  would  afford  passage  to  the  end  of  a  stylet.  I  was  abk 
lo  ascertain,  at  the  same  lime,  that  the  membrane  pressed  upon  by  the  extremity  of 
the  speculum,  possessed  all  the  ruga;,  and  other  characters  of  the  vaginal  mucous 
membrane. 


OVULATION    AND     MENSTRUATION.  109 

As  we  have  already  said,  the  menstrual  blood,  which  is  at  first  small  in 
quantity,  becomes  mixed  with  the  mucosities  which  are  secretel  abundantly 
by  the  vagina  for  a  day  or  two  preceding  the  appearance  of  the  catamenia. 
The  amount  of  blood  soon  increases,  and  the  flow  becomes  almost  exclu- 
sively sanguineous. 

It  is  very  difficult  to  say  whether  the  blood  is  furnished  by  the  arteries 
or  veins,  or  by  both  together.  In  all  probability,  the  blood  exudes  through 
the  walls  of  the  very  delicate  ramuscules  which  form  the  vascular  network 
of  the  innermost  layer  of  the  uterine  mucous  membrane.  The  walls  of  the 
capillaries  ai*e  ruptured,  and  through  this  solution  of  continuity  the  blood 
escapes.     It  is  not,  therefore,  a  true  exhalation. 

Now,  when  gestation  has  progressed  to  some  extent,  these  ramuscules 
become  so  greatly  developed  that  many  of  them  acquire  the  calibre  of  a 
quill.  At  this  time  their  true  nature  may  be  ascertained,  and  the  fact 
settled,  that  they  belong  to  the  venous  system;  so  that  the  menstrual 
hemorrhage  which  they  supply  must  evidently  have  its  source,  in  great 
part  at  least,  in  the  reservoir  of  dark  blood. 

The  physical  characters  of  the  menstrual  blood  vary  according  to  the 
time  at  which  it  is  examined,  since  it  is  mixed  at  the  beginning,  at  the 
middle,  and  at  the  end  of  the  flow,  with  different  amounts  of  vaginal  mucus. 

The  portion  which  escapes  during  the  second  period,  not  only  resembles 
completely  in  external  characters  that  which  is  obtained  directly  from  a 
vein  or  an  artery,  but  is  shown  to  be  identical  by  chemical  analysis.  Its 
slight  coagulability  has  been  regarded  as  an  evidence  of  a  want  of  fibrine ; 
but,  though  it  coagulates  rarely,  as  a  general  fact,  yet  there  are  occasions 
in  which  clots  exist  in  the  vagina,  and  in  the  cavity  of  the  uterus  itself.1 
The  presence  of  fibrine  has  been  chemically  demonstrated,  so  that  though 
the  coagulation  of  the  menstrual  blood  be  of  rare  occurrence,  the  fact  is 
certainly  due  to  its  being  uniformly  mixed  with  a  considerable  amount  of 
vaginal  mucus. 

On  examination  by  the  rectum,  I  found:  1.  That  the  rectal  pouch,  or  dilatation, 
was  much  larger  than  in  the  normal  condition ;  2.  That  above  the  extremity  of  the 
vagina,  when  pressed  upward  by  my  thumb,  the  index  introduced  at  Mie  same  time 
by  the  anus  and  carried  as  high  as  possible,  could  discover  neither  fibrous  cord  nor 
tumor;  nothing,  in  fact,  which  could  lead  to  a  belief  of  the  existence  of  the  upper 
part  of  the  vagina  and  of  a  uterus;  3.  Having  introduced  a  sound  into  the  bladder, 
the  finger  in  the  rectum  perceived  with  the  greatest  ease  that  nothing  intervened 
between  its  palmar  surface  and  the  vesical  sound,  except  the  normal  thickness  of  the 
two  walls  of  the  rectum  and  bladder.  The  sensation  was  identical  with  that  expe- 
rienced when  the  index  is  introduced  into  the  vagina  in  order  to  direct  a  sound  in 
the  urethra. 

From  this  examination  I  thought  myself  justified  in  concluding:  1,  that  the  tumors 
found  in  the  inguinal  regions  were  the  two  ovaries  ;  2,  that  the  lowest  extremity  only 
of  the  vagina  was  present;  3,  that  the  upper  four-fifths  of  that  canal  were  completely 
wanting;  4.  that,  most  probably,  there  was  no  uterus;  6,  that  the  hypogastric  and 
lumbar  pains  which  were  experienced  quite  regularly,  and  almost  monthly,  were  the 
expression  of  periodical  ovarian  operations;  0,  that  the  blood  of  the  menses  which 
bad  appeared  twice  in  this  young  woman,  had  its  origin  in  the  mucous  membrane  of 
the  vagina. 

1  It  is,  however,  right  to  observe,  that  the  presence  of  clots  in  the  menstrual  dis- 
charge is  frequently  due  to  an  alteration  of  the  structure  of  the  uterus,  or,  at  the 
least,  to  a  functional  derangement. 


110  FEMALE  ORGANS  OF  GENERATION. 

The  eruption  of  the  menses  is  generally  attended  with  a  peculiar  odor 
proceeding  at  that  time  from  the  secretions  of  the  vulva;  it  increases  in 
intensity  during  the  flow,  and  has  been  compared  by  some  persons  to  the 
Bmell  of  the  marigold.  Can  it  be  that  the  strange  fears  with  which  men- 
struating women  are  regarded  in  some  countries,  are  attributable  to  this 
odor,  which  in  uncleanly  individuals  is  very  strong?  Although  this  is 
probable,  I  should  think  it  futile  to  discuss  the  incredible  stories  upon 
which  are  based  the  popular  notions  of  the  noxious  properties  of  the  men- 
strual emanations. 

Certain  females  discharge  by  the  vulva,  at  the  menstrual  period,  a  kind 
of  membranous  bag,  which  would  seem  by  its  form  to  have  been  moulded 
upon  the  uterine  cavity,  and  which  bears  a  strong  resemblance  to  the  mem- 
branous pouch  (deciduous  membrane)  which  is  expelled  with  the  ovum  in 
6ome  cases  of  abortion.  The  nature  of  the  pouch  is,  in  fact,  the  same  in 
both  cases,  being  formed  of  cellular  tissue,  which  is  both  vascular  and 
glandular;  its  internal  surface  is  always  smooth,  provided  with  epithelium, 
and  often  abundantly  perforated  with  glandular  orifices.  The  external 
surface,  by  which  it  adhered  to  the  organ  from  which  it  was  separated,  is 
shaggy  and  torn.  It  is  evidently  an  exfoliated  portion  of  the  mucous 
membrane. 

This  exfoliation  usually  occurs  in  such  women  only  as  are  afflicted  with 
difficult  or  very  profuse  menstruation,  accompanied  with  violent  pain  (mem- 
branous dysmenorrhea),  or  in  such  as  experience  a  delay  in  the  appearance 
of  their  courses.  According  to  M.  Coste,  this  phenomenon  is  the  result  of  an 
excessive  congestion,  a  sort  of  apoplexy  of  the  mucous  membrane;  for,  says 
he,  coagula  are  almost  always  found  infiltrated  in  the  substance  of  the 
expelled  membrane.  I  would  add  as  probable,  that,  in  some  cases  at  least, 
this  exaggerated  congestion  may  have  been  the  consequence  of  an  abortive 
conception,  or  perhaps  of  solitary  venereal  excitements. 

Those  physiologists  were  mistaken  who  supposed  that  at  every  menstrual 
period  a  free  secretion  took  place  upon  the  internal  surface  of  the  uterus, 
and  gave  rise  to  a  false  membrane.  Nothing  of  the  kind  has  ever  been 
proved  by  anatomical  investigation  ;  for  the  internal  surface  of  the  uterus, 
at  whatever  moment  examined  during  the  catamenial  period,  always  retains 
the  characters  peculiar  to  the  mucous  membrane,  remaining  smooth,  and 
covered  with  epithelium.  Sometimes,  however,  the  latter  exfoliates,  and 
bears  away  with  it  a  portion  of  the  substance  of  the  mucous  membrane,  in 
which  case,  the  torn  glandular  tubes  rendered  free  and  floating  by  the 
separation,  form,  as  it  were,  a  forest  of  white  filaments,  and  give  accidentally 
to  the  internal  surface  of  the  uterus  the  villous  and  shaggy  appearance 
which  some  authors  have  erroneously  considered  as  normal.  This  circum- 
stance is,  however,  altogether  exceptional,  and  results  from  the  membranous 
exfoliation  of  which  we  have  just  spoken. 

Cause  of  Menstruation.  —  Few  questions  have  given  rise  to  more  lively 
discussions  than  the  cause  of  menstruation ;  I  think  it  useless,  however,  to 
mention  here  the  numerous  and  more  or  less  whimsical  hypotheses  which 
have  successively  appeared  in  reference  to  it.  The  fact  is,  that  after  having 
read  all  that  has  been  written  on  this  subject,  the  mind  rests  entirelv 


OVULATION    AND    MENSTRUATION.  Ill 

satisfied  in  its  ability  to  refer  this  singular  phenomenon  to  one  unchange- 
able and  easily  verified  fact,  namely,  the  successive  evolution  of  the  Graafian 
vesicles.  We  owe  this  satisfactory  explanation  to  the  admirable  labors  of 
Negrier,  Coste,  Pouchet,  Raciborsky,  Robert  Lee,  and  BischofF,  so  that 
the  credit  of  so  beautiful  a  discovery  belongs  almost  exclusively  to  France. 
That  the  cau&e  of  the  menstrual  discharge  is  the  evolution  of  a  Graafian 
vesicle,  would  be  an  indisputable  proposition,  provided  we  are  able  to  show: 

1,  that  the  examination  of  women  who  died  during  or  shortly  after  the  men- 
strual period,  has  uniformly  revealed  the  above-named  changes  in  the  ovary ; 

2,  that  the  absence  of  ovaries  involved  of  necessity  the  absence  of  menstrua- 
tion ;  3,  and  lastly,  that  there  is  a  complete  analogy  between  the  anatomical 
and  physiological  phenomena  of  the  heat  of  animals,  and  those  which 
accompany  menstruation  in  the  human  female. 

1.  Since  attention  has  been  directed  to  this  subject,  no  one  has  succeeded 
in  instancing  the  case  of  a  single  woman,  who  died  at  the  menstrual  period, 
whose  ovary  did  not  present  a  vesicle  in  a  greater  or  less  degree  of  develop- 
ment, or  else  one  which  had  been  already  ruptured.  The  facts  related  by 
Coste,  Negrier,  Pouchet,  Raciborsky,  and  others,  are  now  so  numerous,  that 
it  would  be  impossible  to  reproduce  them  in  a  work  like  the  present.  I 
might  myself  add,  if  it  were  necessary,  a  considerable  number  of  cases  to 
the  others.  This  universal  coincidence  affords  from  the  outset  a  very  strong 
probability  of  the  relation  of  causality  which  we  wish  to  establish ;  but  it 
would  become  an  absolute  certainty,  wei-e  it  possible  to  prove  that  the 
absence  of  the  ovaries  involved  of  necessity  the  absence  of  the  menses. 

2.  In  the  case  of  animals,  on  which  the  experiment  can  be  repeated  at 
pleasure,  not  a  doubt  is  permitted,  that  the  extirpation  of  the  ovaries  causes 
the  disappearance,  forever,  of  all  symptoms  of  heat.  Analogy  alone  would 
lead  us,  in  the  absence  of  positive  facts,  to  suppose  that  menstruation,  also, 
would  cease  after  castration.  But  although  well-observed  instances  of  the 
performance  of  this  operation  on  women  are  happily  very  rare,  there  is  yet 
one  which  derives  a  great  value  in  the  present  discussion  from  the  name  of 
the  author.  The  following  is  an  abridgment  of  it.  A  woman,  says  Percival 
Pott,  had  two  small  tumors,  one  in  each  groin,  which  were  so  painful  as  to 
render  working  impossible.  It  was  decided  to  extirpate  them.  After  hav- 
ing divided  the  skin  and  the  subcutaneous  tissues,  a  membranous  sac  was 
exposed,  which  contained  a  body  resembling  an  ovary  ;  a  ligature  was  thrown 
around  it,  and  it  was  removed.  The  same  operation  was  performed  on  the 
opposite  side.  The  woman  recovered ;  but  the  menstruation,  which  before  had 
occurred  with  the  greatest  regularity,  never  afterwards  appeared ;  the  breasts, 
which  had  been  voluminous,  subsided  ;  she  also  became  thinner,  and  assumed 
a  more  masculine  appearance. 

From  the  statement  of  M.  Roberts  it  would  appear  that  in  Central  Asia, 
vestiges  are  still  to  be  met  with  of  the  cruelty  of  the  ancient  kings  of  Lydia, 
who  castrated  women,  either  that  they  might  put  them  in  charge  of  their 
seraglios,  or  in  order  to  gratify  their  unbridled  passions.  After  arriving  at 
Serai,  he  obtained  a  nocturnal  rendezvous  with  three  persons  known  as 
Padjeras.  The  necks  of  these  individuals  were  not  developed,  nor  had  they 
any  nipple  ;  the  s;  ifice  of  the  vagina  which  was  entirely  obliterate  1,  presented 


112  FEMALE  ORGANS  OF  GENERATION. 

no  trace  of  a  cicatrix  ;  their  hips  were  narrow,  the  pubis  entirely  destitute 
of  hair,  the  nates  were  flattened,  &c. ;  they  had  no  hemorrhoidal  flux.,  no 
epistaxis  nor  menstrual  discharge,  neither  had  they  any  sexual  desires. 
They  were  very  muscular,  and  there  was  something  masculine  both  in  their 
external  appearance  and  in  the  character  of  the  voice. 

M.  Roberts  was  unable  to  ascertain  precisely  the  nature  of  the  operation 
to  which  they  had  been  subjected  in  their  childhood,  for  they  had  no  remem- 
brance of  it ;  but  if  we  may  judge  by  the  results,  which  are  altogether  simi- 
lar to  those  produced  by  castration  in  animals,  it  becomes  more  than  prob- 
able that  the  same  alterations  are  due  to  the  same  cause. 

3.  Admitting,  finally,  the  incontestable  analogy  between  the  symptoms 
of  heat  and  menstruation,  it  will  be  sufficient  to  prove,  in  order  to  deduce 
therefrom  a  favorable  argument,  that  the  former  is  always  connected  in  ani- 
mals with  the  ovarian  evolution.  Now  certain  experiments  do  not  allow  of 
hesitation.  By  these  it  is  in  fact  proved  (Coste),  that  the  females  never 
enter  into  heat  except  when  the  preparation  for  the  spontaneous  ovulation 
is  going  on  in  the  ovaries,  that  the  venereal  erethism  continues  throughout 
the  entire  duration  of  the  process  of  evolution,  and  that  it  ceases  when  the 
rupture  of  the  capsule  has  taken  place.  Finally,  it  is  universally  known 
that  castration  prevents  the  females  from  entering  into  heat,  whilst  those  which 
have  been  deprived  of  the  womb,  but  not  of  the  ovaries,  lose  nothing  of  the 
ardor  with  which  they  receive  the  male. 

Menstruation  is,  therefore,  intimately  connected  with  the  evolution  of  the 
ovarian  vesicles,  and  cannot  occur  without  it ;  and  every  time  that  it  appears, 
we  may  feel  entirely  satisfied  as  to  the  existence  of  the  vesicular  develop- 
ment. But,  as  an  additional  phenomenon,  the  uterine  hemorrhage  may  be 
wanting  without  hindering,  in  any  degree,  the  regular  march  of  the  process 
going  on  in  the  ovary.  In  a  word,  the  spontaneous  ovulation  which  ordi- 
narily gives  rise  to  an  exhalation  of  blood  from  the  internal  surface  of  the 
womb,  may  have  its  influence  restricted  to  the  ovary  alone ;  and  to  assume 
the  non-appearance  of  the  menses  as  a  ground  for  denying  aptitude  for  con- 
ception, would  be  incurring  the  risk  of  frequent  deceptions.  Thus  it  hap- 
pened that  science  possesses  numerous  examples  of  young  girls  who  became 
pregnant  before  they  had  ever  menstruated,  as  also  of  women  who  con- 
ceived, notwithstanding  a  suppression  which  had  lasted  for  several  months. 

On  the  other  hand,  the  regularity  of  the  menstrual  function  dr.es  not 
necessarily  imply  the  entire  fulfilment  of  the  vesicular  evolution.  In  cer- 
tain cases,  the  latter  process  has  been  seen  to  remain  incomplete,  and  the 
vesicle  after  having  attained  a  certain  degree  of  hypertrophy,  to  be  suddenly 
arrested  in  its  development,  to  remain  stationary  for  some  time,  and  then 
abort  without  rupture.  I  have  chanced  to  meet,  says  M.  Coste,  cases  in 
which  the  menstrual  flow  had  passed  over  entirely,  without  the  ovarian  fol- 
licle, whose  evolution  had  commenced  and  even  progressed  to  its  final  period, 
having  ruptured,  or  accomplished  the  result  toward  which  it  tended. 

The  cause  of  menstruation  being  ascertained,  how  shall  we  account  for 
its  monthly  periodicity  ?  In  other  words,  why  is  it  that  ovulation  in  the 
human  species  recurs  about  every  month  ?  To  this  question  science  is 
unable  to  reply,  for  it  is  probably  one  of  the  impenetrable  mysteries  of  nature. 


OVULATION    AND     MENSTRUATION.  113 

But  why  should  our  ignorance  upon  the  subject  be  a  cause  of  wonder?  Do 
we  know  why  certain  trees  produce  new  flowers  every  month  ?  why  this 
animal  is  prepared  for  fecundation  every  two  or  three  months,  whilst  that 
one  is  so  but  once  a  year?  The  processes  which  we  have  studied  are  inti- 
mately connected  with  fecundation,  and  are,  so  to  speak,  its  preludes.  Why, 
when  the  whole  book  is  unintelligible  to  us,  should  we  expect  to  compre- 
hend the  preface  ? 

Cessation  of  the  Menses. — As  we  have  before  said,  the  menses  continue  in 
the  majority  of  women  until  about  the  age  of  45  years.  According  to  a 
table  of  Brierre  de  Boismont,  40  years  is  the  age  at  which  the  greater  num- 
ber of  women  cease  to  be  regular.  In  60  women  observed  by  M.  Petrequin, 
it  was  between  35  and  40  years  in  i,  between  40  and  45  in  £,  between  45 
and  50  in  \,  and  between  50  and  55  in  k.  In  110  women  mentioned  by  M. 
Raciborsky,  the  average  age  of  cessation  was  46  years.  The  latter  author 
cites  from  Dr.  Lebrun  of  Varsovia,  and  Faye  of  Skeen,  results  which  go  to 
prove  that  in  Poland  the  average  term  is  47  years,  and  in  the  neighborhood 
of  Christiana  48 ;  all  which  tends  to  show  that  in  cold  climates  menstrua- 
tion terminates  later  in  life.  It  may  be  admitted,  therefore,  that  the  aver- 
age duration  of  the  menstrual  function  is  from  25  to  30  years. 

But  like  their  commencement,  the  period  at  which  the  menses  cease  ia 
subject  to  great  variation.  Desmoreaux  mentions  a  lady  with  whom  they 
stopped  at  23  years  of  age;  nor  is  it  rare  to  find  them  suppressed  between 
35  and  40.  On  the  other  hand,  they  are  often  prolonged  much  beyond  the 
ordinary  period,  and  with  them,  the  women  retain  the  power  of  conception 
up  to  60,  65,  and  even,  as  some  authors  relate,  to  70  years.  I  leave  to  the 
lovers  of  the  marvellous  those  instances  in  which  menstruation  continued 
until  80,  90,  and  even  106  years.  It  is  infinitely  probable  that,  in  the  cases 
of  this  nature,  the  pretended  menstrual  returns  were  really  due,  as  Haller 
remarks,  to  uterine  disease.  I  would  add,  that  we  should  place  in  the  same 
category  those  examples  of  women  who,  after  having  ceased  to  menstruate 
about  the  age  of  45  or  50  years,  have  had  their  courses  to  reappear  several 
years  after,  and  continue  with  regularity. 

According  to  most  authors,  those  women  who  menstruate  very  early  also 
cease  to  do  so  sooner  than  others.  This  remark  appears,  both  to  M.  Raci- 
borsky and  myself,  to  be  inexact,  when  not  applied  to  individuals  living 
under  different  climates.  With  the  former  author,  we  think  that  preco- 
cious menstruation  is  due  to  an  excels  of  vital  power  in  the  individual,  and 
that,  exceptional  circumstances  excluded,  the  influence  of  this  vital  activity 
is  felt  later  in  life,  and  prolongs  the  aptitude  for  procreation  in  the  woman. 
So  that,  in  general,  it  ceases  as  much  later  as  it  begins  at  an  earlier  age. 

The  cessation  of  the  menses,  and  of  the  vesicular  evolution  of  which  they 
are  an  epiphenomenon,  produces  in  the  generative  apparatus  and  entire 
organism  of  the  woman,  effects  the  opposite  of  those  which  their  first  appear- 
ance had  determined. 

The  ovaries  become  atrophied,  and  diminish  in  size  in  every  direction, 
and  their  external  envelope  becomes  folded  and  wrinkled,  so  as  to  present 
an  appearance  which,  says  M.  Raciborsky,  we   can  compare  to   nothing 
better  than  the  surface  of  a  peach-stone. 
8 


114  FEMALE  ORGAN'S  OF  GENERATION. 

The  Graafian  vesicles  appear  as  pouches  of  a  grayish  or  opaque  white 
color,  with  wrinkled  walls;  the  fluid  which  they  contained  is  absorbed; 
sometimes  their  cavities  are  effaced,  their  thickened  walls  are  in  contact, 
and  look  like  a  sort  of  tubercle,  in  the  centre  of  which  barely  a  trace  of 
the  former  cavity  is  visible.  Sometimes  no  part  of  the  vesicles  can  be 
diycovered,  and  the  ovary,  which  has  become  transformed  into  a  fibro- 
cellular  substance,  is  so  flattened  as  to  be  hardly  distinguishable  at  the 
extremity  of  its  ligament.  We  have  already  spoken  of  the  deep  folds  and 
wrinkles  of  its  external  membrane. 

Finally,  the  womb  and  the  breasts,  whose  vitality  became  suddenly  so 
active  towards  the  age  of  puberty,  seem  struck  with  the  same  blow  which 
destroyed  the  ovarian  orgasm ;  they  waste  gradually  away,  and  become,  so 
to  speak,  foreign  to  the  general  life  of  the  body. 

This  cessation  of  the  ovarian  functions  rarely  takes  place  suddenly,  but 
is  almost  always  announced  several  years  in  advance  by  more  or  less 
marked  irregularities  or  intermissions.  Frequently,  the  returns  of  the 
menses  suffer  postponements,  which  may  be  prolonged  for  several  weeks  or 
months,  and  then,  after  renewal,  be  deferred  for  a  still  longer  period. 
Sometimes  the  epochs  are  marked  by  a  very  small  discharge,  and  last  for  a 
very  short  time ;  again,  on  the  contrary,  the  quantity  of  blood  lost  may  be 
so  considerable  as  to  give  rise  to  apprehension.  With  certain  women  the 
flow  is  so  excessively  prolonged  that  the  menstrual  periods  are  only 
indicated  by  its  increase ;  a  mucous  flux  of  a  yellowish-white  color,  which 
is  quite  abundant,  and  either  continuous  or  periodic,  replaces  the  flow  of 
blood  in  the  interval  of  the  epochs,  and  sometimes  remains  for  a  long  time 
after  they  have  ceased.  Finally,  a  general  and  indefinite  feeling  of  uneasi- 
ness, lumbar  and  pelvic  pains,  colics,  itching  at  the  genital  parts,  flashes  of 
heat  in  the  face,  and  sudden  and  spontaneous  alterations  of  chilliness  with 
profuse  perspirations,  are  added  to  the  local  phenomena  above  indicated. 

In  the  majority  of  cases,  all  these  troubles  are  quite  slight  and  disappear 
promptly ;  but,  in  some  instances,  diseases  before  latent  then  declare  them- 
selves. It  is  this  fact  which,  though  much  rarer  than  is  commonly  supposed, 
has  obtained  for  this  time  of  life  the  name  of  the  critical  period.  Its 
dangers  have  been  wonderfully  exaggerated,  and  modern  researches  prove, 
in  opposition  to  the  opinion  of  physicians  who  have  preceded  us,  that  the 
organic  affections  of  the  breasts,  of  the  uterus,  and  of  the  ovaries,  begin 
much  more  frequently  before  than  after  the  cessation  of  the  menses.  Finally, 
it  is  shown  by  statistics,  that  the  mortality  in  women  between  the  ages  of 
4' i  and  50  years  is  not  greater  than  at  any  other  period  of  life. 


OF    THE    BREASTS.  115 

CHAPTER  V. 

OF    THE    BREASTS. 

[The  breasts,  two  in  number,  are  large  glands,  annexes,  so  to  speak,  of  the  organs 
of  generation.  They  are  symmetrically  placed  on  the  upper  and  anterior  part  of  the 
thomx  on  each  side  of  the  sternum,  generally  occupying  the  space  included  between 
the  third  and  fifth  ribs.  Rudimentary  in  -man  and  in  the  young  girl,  they  become 
developed  in  the  latter  at  the  period  of  puberty.  They  present  great  individual 
difference  in  size,  hut  in  the  women  of  certain  races  they  are  generally  very  large, 
some  African  nations,  for  example,  having  them  extremely  long. 

The  left  breast  is  often  larger  than  the  right  one.  Curious  anomalies,  also,  some- 
times come  under  observation.  Thus,  women  are  reported  having  four  breasts,  and 
I  have  myself  met  with  an  instance  of  this  kind  in  a  woman  who  died  at  the 
Maternity  Hospital.  Two  breasts  of  the  usual  size  occupied  their  normal  position, 
whilst  two  others,  as  fully  developed,  were  situated  on  the  upper  and  lateral  parts 
of  the  abdomen  on  the  same  vertical  line  with  the  thoracic  ones.  At  the  autopsy, 
I  found  abundance  of  glandular  tissue  in  all  four  of  the  breasts,  which  also  con- 
tained milk. 

A  supplementary  nipple  at  a  short  distance  from  the  principal  one,  is  a  more 
frequent  anomaly,  of  which  I  have  already  seen  several  examples.  A  wax  model 
from  a  cast  of  one  of  these  is  now  in  the  collection  of  the  hospital  of  the  "  Clinique." 
In  the  instances  which  have  come  under  my  observation,  the  supplementary  nipple 
was  well  formed,  but  smaller  than  the  normal  one,  and  milk  flowed  from  it  when 
the  gland  was  pressed.  One  of  the  women  assured  me  that  the  peculiarity  was 
hereditary  in  her  family. 

The  natural  form  of  the  breast  is  hemispherical,  or  rather  represents  a  flattened 
cone  with  the  base  upon  the  chest.  The  skin  covering  it  presents  in  its  centre  a 
projection  known  as  the  nipple.  Around  the  nipple  isacolored  circle,  from  an  inch 
and  a  quarter  to  rather  more  than  an  inch  and  a  half  in  diameter,  called  the  areola, 
and  is  easily  distinguished  by  its  contrasted  hue.  Some  further  remarks  will  be 
necessary  to  the  proper  study  of  all  these  parts. 

The  skin  covering  the  breasts  is  fine  and  soft,  and  is  provided  with  piliferous 
follicles  to  which  are  connected  large  sebaceous  glands.  The  hairs  are  extremely 
fine  and  readily  seen  only  when  magnified.  Beneath  the  skin,  and  between  it  and 
the  gland  proper,  is  a  layer  of  cellulo-adipose  tissue,  which  increases  in  thickness 
in  approaching  the  circumference  of  the  organ.  To  this  fatty  layer  the  breasts  owe 
their  regularly  rounded  form,  their  softness,  and  very  often  the  greater  part  of  their 
size. 

The  areola  is  rose-colored  in  young  women,  and  brown  in  those  who  have 
borne  children.  The  skin  covering  it  is  rugous,  abundantly  furnished  with  seba- 
ceous glands,  and  exhibits  here  and  there  tuberculous  elevations  of  variable  size. 
These  projections,  numbering  from  twelve  to  twenty,  have  a  somewhat  circular 
arrangement,  and  are  composed  of  collections  of  highly  developed  sebaceous  glands 
which  secrete  a  yellowish-white  fluid.  The  character  of  the  secretion  was  doubtless 
the  cause  of  their  having  been  so  long  regarded  as  rudimentary  nipples  giving  issue 
to  drops  of  milk.  This  erroneous  view  can  no  longer  be  maintained  since  they  are 
proved  to  be  sebaceous  glands. 

The  areola  does  not  rest  upon  a  fatty  cushion  like  the  remainder  of  the  skin  of" 
the  breast,  but  is  in  direct  relation  with  the  gland  ;  its  lower  surface,  however,  is 
provided  with  a  layer  of  smooth  muscular  fibres  disposed  around  the  nipple  in  close 
concentric  circles,  which  become  more  widely  separated  toward  the  edge  of  tht 


116 


FEMALE  ORGANS  OF  GENERATION. 


Fio.  38. 


areola  where  they  finally  disappear.  The  skin-muscle  thus  formed  compresses  the 
nipple  when  it  contracts.  Under  its  action  also,  the  skin  of  the  areola  contracts 
and  wrinkles  if  the  nipple  be  excited  by  tickling. 

The  nipple,  situated  in  the  centre  of  the  areola,  presents  a  slightly  conical  pro 
jection,  from  three  to  five  eighths  of  an  inch  in  height  and  from  five-sixteenths  to 
three-eighths  of  an  inch  in  diameter  at  the  base.  These  dimensions,  however,  as 
well  as  the  shape  of  the  nipple,  vary  greatly.  In  some  women  it  is  very  slightlj 
developed  and  barely  projects  at  all ;  in  others,  it  is  actually  below  the  surface  of 
the  areola,  presenting  a  sort  of  umbilical  depression.  On  the  other  hand  it  may 
be  very  large  or  even  club-shaped.  The  skin  covering  it  presents  numerous 
papillae,  separated  by  creases  in  the  bottom  of  which  are  the  orifices  of  great 
numbers  of  sebaceous  glands.  Beneath  the  skin  are  connective  tissue,  elastic 
tissue,  and  bundles  of  muscular  fibres. 

This  structure  explains  sufficiently  why  touching  the  nipple  should,  by  exciting 
contraction  of  the  fibres  which  it  contains,  render  it  for  the  moment  harder  and 
more  projecting.  Still,  it  must  not  be  confounded  with  the  truly  erectile  organs, 
inasmuch  as  its  arteries  are  small  and  not  contorted  and  the  veins  also  of  small 
size. 

The  nipple  is  traversed  from  base  to  summit  by  lactiferous  ducts  fifteen  or  twenty 
in  number,  which  open  by  as  many  minute  orifices  near  the  free  extremity  of  the 
organ  at  the  bottom  of  the  folds  between  the  papillae. 

The  mammary  gland  proper,  is  situated  beneath  the  parts  just  described,  in  a  fold 

of  the  fascia  superficialis.  It  presents  a  hard, 
flattened  mass  which  is  thicker  at  the  centre  than 
at  the  circumference.  The  glandular  structure  is 
disposed  in  fifteen  or  twenty  lobes,  separated  by  a 
fibrous  envelope  surrounded  by  fatty  tissue. 

Each  lobe  is  formed  by  the  aggregation  of  a  cer- 
tain number  of  lobules,  themselves  composed  of 
glandular  culs-de-sac  or  acini  dilated  into  terminal 
vesicles.  From  each  vesicle  departs  a  minute  duct 
-jj  which  joins  those  of  neighboring  acini.  The  ducts 
from  the  lobules  unite  in  their  turn  to  form  in 
each  lobe  a  principal  canal  which  has  received  the 
name  of  lactiferous  duct. 

As  each  lobe  has  its  principal  or  lactiferous  duct, 
the  whole  number  of  these  vessels  is  the  same,  e.  g. 
fifteen  or  twenty,  as  that  of  the  lobes. 

The    lactiferous  ducts  all    proceed    toward    the 

nipple,  but  in  passing  under  the  areola  they  ex 

hibit  dilatations  which  have  received  the  name  of 

sinuses.     Then  entering  the  nipple,  they  diminish 

in  size  and  terminate  by  separate  and  very  minute 

openings. 

It  is  most  probable  that  the  lactiferous  ducts  are  independent  of  each  other 

throughout  their  extent.     Prof.  Dubois,  indeed,  expressed  the  opinion  that  they 

often  anastomose;  but  M.  Sappey,  who  has  investigated  the  subject  more  recently, 

failed  to  discover  any  connection  between  them. 

The  fact  that  the  walls  of  these  ducts  are  provided  with  muscular  fibres  is  suffi- 
cient to  explain  the  spirting  out  of  the  milk  when  they  contract. 

The  arteries  of  the  breast  come  from  the  external  and  internal  mammary  and  the 
intercostal  arteries. 

The  veins  follow  the  same  course  with  the  arteries,  and  empty,  some  into  the 
internal  mammary,  and  others  into  the  axillary  vein. 


Lobules  of  a  mammary  gland. 

A.  Acini. 

B.  Canaliculi. 

C.  Duct  formed  by  several  canaliculi. 


OF   THE    BREASTS. 


117 


The  lymphatic  vessels,  which  are  very  abundant,  pass  into  the  axillary  ganglia. 
The   nerves   come    from   the    intercostal  and   thoracic    branches   of    the    brachial 
plexus.] 


Fig.  39. 


C 

Mammary  gland  of  human  female  (Liegeois).     a.  Nipple,     b.  Areola.     C,C,C,C,C.  Loonies  of  the  gland. 
1.  Sinus,  or  dilated  portion  of  one  of  the  lactiferous  ducts.     2.  Extremities  of  the  lactiferous  ducts. 


COMPOSITION    OF    HUMAN    MILK 

The  following  table,  from    Professor    Flint's   Physiology, 
from  various  analyses,  and  is  probably  the  most  trustworthy 

Water  .... 

Caseine  (desiccated)  . 
Lacto-proteine    . 
Albumen     .... 


was  compiled  by  Robin 


{Margarine 
Oleine     . 
Butyrine,  Caprine, 
Sugar  of  milk  (lactine,  or  lactose) 
Lactate  of  soda  (?)     . 
Chloride  of  sodium 
Chloride  of  potassium 
Carbonate  of  soda 
Carbonate  of  lime 
Phosphate  of  lime  of  the  bones 
Phosphate  of  magnesia 
Phosphate  of  soda 
Phosphate  of  iron  (?) 
Sulphate  of  soda 
Sulphate  of  potassa  . 


Caproi'ne, 


Gases  in  solution 


Oxygon  . 
Nit  rogen 
Carbonic 


acid 


.  1.29) 
.  12.17  \ 
.    16.54  j 


to  863.1  Ifl 

"     89.000 

•'       2.770 

0.880 

"     25.8-10 

■•     11.400 

Capriline  .  0.500    "       0.760 

■•     49.000 

"      0  i  SO 

0.340 

1  830 

0.056 

"      0.070 

8.440 

0.640 

0.280 

«      0.070 

••      0.075 

races. 

1.000.000     1.000.000 

80  parts  per  1.000  in  volume.     |  Hoppe.  | 


902.717 

29.000 

1 .000 

traces 

'  17.000 
7.600 
0.500 
87.000 
0.420 
0.240 
1.440 
0.053 
0.069 
2.810 
0.420 
0.225 
0.082 
0.074 
t 


PART  II. 
OF  PKEGNANOY. 

GENERATION  is  effected  in  the  human  species  through  the  medium  of 
two  sexes  distinguished  by  the  possession  of  different  organs.  The 
sexual  characters  being  therefore  peculiar  to  distinct  individuals,  the  male 
and  the  female,  these  evidently  must  first  approach  each  other  before 
generation  can  take  place.  This  first  act  constitutes  copulation.  The  con- 
sequence of  the  approach  is  an  application  of  the  fecundating  principle  of 
the  male  to  the  germ  furnished  by  the  female,  in  other  words,  conception  or 
fecundation.  The  ovum  having  been  fecundated,  remains,  and  is  developed 
in  the  organs  of  the  mother  during  the  whole  term  of  gestation.  Lastly,  at 
the  expiration  of  a  nearly  uniform  period,  the  new  being  is  expelled,  to 
maintain  thenceforth  a  separate  existence ;  this  final  act  is  termed  the 
accouchement  or  labor. 

Pregnancy  is,  therefore,  the  condition  of  a  woman  who  has  conceived,  and 
bears  within  her  womb  the  product  of  conception. 

This  state  commences  at  the  instant  of  fecundation,  and  terminates  with 
the  expulsion  of  the  body  which  results  from  that  function.  It  continues 
for  two  hundred  and  seventy  days,  or  nine  solar  months.  This  te^ni,  how- 
ever, is  not  invariable,  as  it  is  by  no  means  rare  for  the  pregnancy  to 
terminate  sooner,  and  in  some  very  few  instances  we  find  it  of  longer  duration, 
though  some  persons  have  denied  this  latter  fact,  and  everybody  recalls  the 
sharp  discussions  carried  on  in  France  about  the  middle  of  the  last  century, 
and  still  more  recently  in  England,  on  the  question  of  retarded  births. 

We  have  already  stated  that  the  fecundated  ovule  traverses  the  tube,  so 
as  to  reach  the  uterus,  where  it  is  developed  and  continues  to  grow  during 
the  whole  term  of  gestation.  When  the  succession  takes  place  in  this 
manner,  the  pregnancy  is  said  to  be  a  good,  normal,  or  uterine  one ;  but,  on 
J,he  contrary,  if  the  ovule  be  arrested  at  some  point  of  its  passage,  and  is 
developed  elsewhere  than  in  the  womb,  the  pregnancy  is  denominated  bad, 
extraordinary,  or  extra-uterine.  The  first,  or  uterine  pregnancy,  has  been 
divided  into, — the  simple,  where  only  a  single  foetus  exists;  the  compound,  or 
double,  triple,  &c,  where  there  are  two  or  three  children ;  and  the  com- 
plicated pregnancy,  or  that  in  which  the  positive  existence  of  a  foetus  is 
coincident  with  that  of  a  pathological  tumor  of  the  abdomen.  Again,  the 
term  false  pregnancy  has  been  improperly  applied  to  certain  diseases  simulat- 
ing pregnancy,  where  this  state  does  not  really  exist. 

We  shall  first  treat  of  simple  pregnancy,  leaving  the  subject  of  twin 
pregnancies  for  a  special  chapter.  Extra-uterine  pregnancy  will  be  studied 
with  the  other  diseases  of  the  pregnant  female. 

IIS 


OF    CONCEPTION.  119 

The  pregnant  condition  presents  two  classes  of  phenomena,  one  of  which 
pertains  to  the  woman,  and  the  other  to  the  produst  of  conception  they 
are  to  be  studied  separately. 

We  have  already  described  the  genital  organs  of  the  female,  and  it  is  not 
our  province  to  notice  those  of  the  male.  We  shall  be  equally  silent  upon 
all  that  relates  to  sexual  intercourse,  though  it  is  our  purpose  to  treat 
briefly  of  conception,  and  in  detail  of  gestation. 


CHAPTER  I. 

OF   CONCEPTION. 

Conception  takes  place  during  sexual  congress ;  but  to  understand  how 
it  occurs,  requires  that  we  should  know  first  what  materials  are  furnished 
by  each  individual,  how  and  where  these  are  brought  into  contact,  and 
lastly,  what  is  not  yet,  and  probably  never  will  be  explained,  how  from 
this  contact  a  new  individual  is  produced. 

1.  The  spermatic  fluid,  a  glutinous,  consistent,  and  whitish  liquid  secreted 
by  the  testicle,  is  the  fecundating  principle  furnished  by  the  male.  It  is 
heavier  than  water,  and,  when  shaken  with  it,  forms  an  emulsion.  Its  odor 
is  peculiar,  and  has  been  justly  compared  to  that  emitted  by  bone  filings, 
or  the  flower  of  the  chestnut-tree;  Wagner  states  that  the  odor  is  due  rather 
to  the  secretions  with  which  it  is  mixed  than  to  the  sperm  itself,  the  latter, 
when  pure,  not  appearing  to  possess  any  particular  smell.  By  chemical 
analysis  it  is  shown  to  contain  albumen,  salts  of  phosphoric  and  chloro- 
hydric  acids,  and  a  peculiar  animal  substance  called  spermatine. 

When  examined  under  the  microscope,  with  a  magnifying  power  of  three 
or  four  hundred  diameters,  the  spermatic  fluid  exhibits:  1.  A  great  numbei 
of  little  bodies,  lying  quite  close  to  each  other,  and  which  are  still  moving 
with  more  or  less  activity  if  the  fluid  has  been  taken  from  a  recently-killed 
animal;  these  minute  bodies  have  been  designated  as  the  spermatic  animal- 
cules, or  the  spermatozoa.  2.  Epithelial  cells  and  minute  granules  of  a  fatty 
nature.  3.  These  two  principal  elements  of  the  sperm  swim  in  a  small 
quantity  of  clear,  transparent,  and  perfectly  homogeneous  liquid,  —  the 
spermatic  liquid.  At  the  time  of  the  ejaculation,  this  liquid  is  mixed  with 
a  variable  quantity  of  the  fluids  secreted  by  the  prostate  gland  and  the 
glands  of  Cowper,  which  latter  evidently  serve  merely  to  lubricate  the  pa  its, 
to  render  the  sperm  more  fluid,  and,  consequently,  its  expulsion  more  easy. 

The  spermatic  animalcules  attract  particular  attention  by  their  varied 
form,  their  vital  properties,  and  their  development.  They  are  nut  with  in 
all  animals  capable  of  reproduction. 

In  man  they  are  very  small,  scarcely  surpassing  the  eightieth  or  the 
Hundredth  of  a  line  in  diameter.  The  body  is  small,  oval,  Bomewhat 
flattened  like  an  almond,  and  transparent,  having  a  diameter  equal  to  the 
three  or  four  hundredth  part  of  a  millimetre  (/001  of  an  inch  |.  The  tail  is 
filiform,  thicker  at  its  origin  than  at  any  other  part,  and  is  Large  enough  to 
present  clearly  its  double  outline;  towards  the  extremity  it  becomes  so  line 


120  PREGNANCY. 

that  it  cannot  be  traced,  even  by  means  of  the  highest  magnifying  power 
whence  it  may  be  possible  that  its  delicate  extremity  is  still  furthei 
elongated,  and  that  the  spermatozoa  may  be  much  longer  than  they  appear 

It  is  impossible,  says  Wagner  (from  whose  able  works  I  extract  this 
paragraph),  to  decide  whether  the  spermatic  animalcules  have  an  animal 
organization,  that  is,  whether  they  are  true  animals  with  an  independent 
life,  or  not;  and  all  that  is  either  known,  or  plausibly  supposed  on  this 
point,  may  be  reduced  to  a  few  obscure  indications,  that  are  wholly  insuffi- 
cient to  establish  any  positive  opinion. 

The  movements  which  they  exhibit  prove  nothing,  because  it  is  exceed- 
ingly difficult  to  ascertain  whether  they  are  voluntary  or  not.  Again,  the 
duration  of  the  movements  also  varies  in  the  different  classes  of  animals ; 
in  the  mammalia,  they  have  been  observed  for  twenty-four  hours  after  death. 

The  spermatozoa  do  not  appear  in  the  human  species  before  puberty;  at 
this  period,  the  testicles  receive  a  large  supply  of  blood,  and  increase  in 
Bize  ;  the  parietes  of  the  semeniferous  tubes  become  thickened,  their  capacity 
increases,  and  they  are  filled  with  granules ;  then  cells  containing  globules 
begin  to  form,  and  finally  the  spermatozoa  appear  in  these  cells.  They  are 
always  found  in  the  testicles  of  men  of  sixty  to  seventy  years  of  age,  though 
they  are  then  frequently  absent  from  the  vas  deferens ;  the  vesiculse  semi- 
nales,  however,  generally  contain  them  even  at  this  time  of  life. 

The  germ  furnished  by  the  female  is  evidently  existent  in  the  ovary  at 
the  marriageable  period,  and  this  germ  is  the  ovule.  (See  p.  90  for  its 
description.) 

2.  It  is  unnecessary  in  our  day  to  prove  that  an  absolute  contact  of  the 
semen  of  the  male  with  the  ovule  of  the  female  is  indispensable  to  fecun- 
dation, for  innumerable  experiments  upon  living  animals,  and  numerous 
facts  observed  in  the  human  species,  have  long  since  demonstrated  that, 
whenever  any  obstacle  prevents  the  approach  of  these  two  elements,  a  con- 
ception cannot  take  place.  But  at  what  point  does  this  contact  occur? 
Already  had  the  pre-existence  of  the  ovule  in  the  ovary,  the  occasional 
occurrence  of  ovarian  and  abdominal  pregnancies,  and  the  experiments 
of  Nuck  and  Haighton,  which  had  rendered  fecundation  impossible  by 
ligating  the  Fallopian  tubes,  tended  towards  the  conclusion  that  it  occurred 
in  the  ovary;  still  this  fact  was  not  actually  demonstrated,  and  it  needed 
the  definitive  proof  of  finding  the  spermatozoa  on  the  ovary  itself.  At 
present,  there  cannot  be  a  further  doubt  on  this  point,  for  Bischoff  has 
been  fortunate  enough  to  see  them  there.  "I  had  often  seen,"  says  he, 
"living  and  moving  spermatozoa  in  the  vagina,  the  womb,  and  the  Fal- 
lopian tubes  of  bitches;  but,  on  the  22d  of  June,  1838,  I  had  the  good 
fortune  to  perceive  one  on  the  ovary  itself  of  a  young  bitch  in  heat  for  the 
first  time;  she  was  covered  on  the  21st,  at  seven  o'clock  in  the  evening, 
and  again  the  following  day,  at  two  o'clock  p.  M.,  and  at  the  expiration  of 
half  an  hour,  that  is,  twenty  hours  after  the  first  copulation,  I  killed  her, 
and  found  some  living  spermatozoa,  endowed  with  very  active  movements, 
not  only  in  the  vagina,  the  entire  womb  and  tubes,  but  even  between  the 
fringes  of  the  latter  in  the  peritoneal  pouch  that  surrounds  the  ovary,  and 
on  the  surface  of  this  organ  itself."  Since  that  period,  Wagner  and  Barry 
have  made  the  same  observations. 


OF    CONCEPTION.  121 

Now  such  results  evidently  prove  that  fecundation  sometimes  takes  place 
in  the  ovary ;  but  are  we  hence  to  conclude,  thai  it  is  possible  in  that 
organ  alone  ?  If  spontaneous  ovulation  be  now  an  incontestable  fact,  may 
it  not  be  supposed  that  the  ovule,  after  having  left  the  ovary,  can  encounter 
the  spermatic  fluid  and  become  fecundated,  whether  it  be  in  the  Fallopian 
tube,  or  even  in  the  uterine  cavity  ? 

[M  Coste's  observations  seem,  however,  to  prove  that  fecundation  is  almost 
always  effected  either  upon  the  ovary  or  in  the  part  of  the  tube  nearest  the  fim- 
briated extremity  ;  inasmuch  as  he  maintains  that  the  ovule  spoils  very  quickly 
when  it  enters  the  tube  without  previous  fecundation.] 

But  the  question  arises,  how  does  the  fluid  ejaculated  by  the  male  get  as 
far  as  the  ovary  ?  We  answer  that,  in  the  great  majority  of  cases,  it  is 
evident  that  the  sperm  having  first  reached  the  uterus,  upon  the  neck  of 
which  it  was  thrown  by  the  membrura  virile,  travels  through  the  tube  until 
it  arrives  there.  This  course  is  certainly  due,  1st,  to  the  movements  proper 
of  the  womb  and  the  tubes ;  for  in  the  latter,  a  rapid  contraction  is  ob- 
served, following  the  direction  from  the  vagina  towards  the  ovary,  which, 
of  course,  is  calculated  to  assist  the  progression  of  the  sperm  ;  and  2d,  to 
the  movements  proper  of  the  spermatozoa,  which  thus  of  themselves  facil- 
itate their  own  advancement. 

3.  This  first  point  being  once  established,  the  question  naturally  arises, 
what  was  the  influence  exercised  by  the  sperm  upon  the  ovule  of  the  female 
during  the  contact?  Now,  numerous  experiments  clearly  prove  that  the 
sperm  owes  its  fecundating  properties  to  the  presence  of  the  spermatic 
animalcules,  and  that,  whenever  it  is  deprived  of  these,  it  immediately 
becomes  unsuited  to  its  proper  function.  But,  unfortunately,  it  is  far 
more  difficult  to  ascertain  the  part  acted  by  the  spermatozoa,  though  there 
have  been  three  hypotheses  started  in  regard  to  that  subject  deserving  our 
consideration. 

Again,  according  to  certain  authors,  the  fecundating  power  does  not 
belong  to  the  spermatozoa,  but  to  the  seminal  liquid  interposed  between 
them.  In  this  hyrjothesis,  the  animalcules  are  the  transporters  of  this 
fluid,  and  the  object  of  their  movements  is  to  conduct  it  to  the  ovule. 

In  the  opinion  of  Bory-Saint-Vincent,  Valentin,  and  Bischoff,  the  sper- 
matozoa are  solely  destined  to  maintain  the  chemical  composition  of  the 
sperm  by  their  active  motions.  They  suppose  that  the  spermatic  fluid  i.s 
a  substance  endowed  with  a  chemical  sensibility  of  such  a  character  that, 
like  the  blood,  it  can  only  preserve  the  fecundating  power  while  it  remains 
in  motion  ;  whence  these  active  elements  are  inclosed  in  it  whose  presence 
is  indispensable  —  elements,  the  movements  of  which  are  never  more  active 
than  just  at  the  moment  when  the  semen  leaves  the  place  of  its  secretion, 
and  which  appear  to  exercise  the  most  favorable  influence  for  the  main- 
tenance of  its  composition. 

fThe  oldest  view  is,  that  during  fecundation  the  spermatozoids  penetrate  directly 
into  the  ovum.  Barry  even  asserted  that  there  existed  in  the  ova  of  rabbits  an 
opening  for  this  purpose,  and  he  had  once  the  good  fortune  to  see  a  spermatozooc 
enter  by  means  of  the  fissure. 


122  PREGNANCY. 

For  a  long  time  this  view  was  thoroughly  contested,  hut  has  now  come  into 
favor  again.  In  1854,  Meissner  saw  in  the  ova  of  a  rahhit  soermatnzoa  within  the 
transparent  zone  and  in  immediate  contact  with  the  yolk.  The  observation  was 
verified  by  Wagner,  Heale,  and  several  others ;  and  M.  Coste,  whilst  examining  the 
ova  of  salmon  and  trout,  discovered  in  the  vitelline  membrane  a  well-defined 
microscopic  opening  provided  with  an  internal  valve.  In  other  ova,  M.  Robin 
saw  spermatozoa  inside  of  the  vitelline  membrane  without  being  able  to  discover 
the  opening  through  which  they  had  passed. 

Similar  observations  have  become  so  numerous,  that  the  passage  of  more  or  lean 
spermatozoa  into  the  ovum  itself  is  regarded  as  an  established  fact.  Once  within 
the  ovum,  they  undergo  a  retrograde  metamorphosis,  and  are  resolved  into  granula- 
tions which  mingle  with  the  elements  of  the  vitellus  or  yolk.] 

This  is  a  summary  of  the  most  recent  opinions.  Whichever  one  may 
he  adopted,  the  mind  remains  unsatisfied ;  for  it  must  be  acknowledged 
there  is  still  a  mystery  that  all  the  most  ingenious  hypotheses  have  failed 
to  solve,  and  which  will  probably  escape  all  our  researches. 

When  fecundation  takes  place,  the  Fallopian  tubes,  which  participate 
in  the  stage  of  turgescence  of  all  the  other  genital  organs,  retain  their  free 
extremities  in  contact  with  the  ovary,  and  the  ovule,  having  escaped  from 
the  vesicle,  immediately  engages  in  their  canal ;  being  pressed  onwards  by 
the  peristaltic  contractions  of  the  tube,  it  advances  step  by  step  through 
this  duct,  and  finally  arrives  in  the  uterine  cavity,  where  its  development 
unceasingly  progresses  until  the  regular  term  of  pregnancy.  (See  the 
chapter  on  Ovology.) 

Nearly  the  same  phenomena  take  place,  when  the  contact  of  the  fecun- 
dating fluid  with  the  ovule  is  deferred  until  after  the  latter  has  passed  into 
the  tube. 

It  is  extremely  difficult,  not  to  say  impossible,  to  ascertain  the  exact 
period  at  which  the  fecundated  ovule  reaches  the  cavity  of  the  womb.  In 
animals,  we  may  note  without  difficulty  the  time  of  fecundation ;  but  this, 
of  course,  is  generally  impossible  in  the  human  species,  and  this  obstacle 
renders  nearly  all  our  observations  uncertain  and  incomplete.  Further,  very 
numerous  researches  have  clearly  proved  that  the  ovule  in  mammalia  does 
not  always  arrive  at  the  same  moment  in  the  womb,  and  it  is  exceedingly 
probable  that  the  same  variations  exist  in  the  human  female. 

In  the  present  records  of  our  science,  there  is  no  one  conclusive  fact  that 
proves  the  ovule  to  have  ever  been  seen  in  the  womb  of  a  woman  prior  to 
the  tenth  or  twelfth  day  after  her  conception. 

Baer  examined  a  woman,  who  committed  suicide  eight  days  after  con- 
ception ;  the  deciduous  membrane  had  commenced  forming,  but  he  could 
not  detect  any  trace  of  the  ovule  in  the  uterus.  (British  and  Foreign  New 
Review,  January,  1836,  p.  328).  The  same  occurred  in  the  cases  cited  by 
Weber  (Disquisitio  anatomica  uteri  et  ovariorum  puellce,  septimo  a  conccpitione 
die  defunctce  instituta).  Dr.  Pockels  speaks,  it  is  true,  of  an  ovum  of  eight 
days,  found  in  the  uterus,  and  in  which  the  fcetus  could  easily  be  distinguished; 
but  the  description  furnished  by  him  evidently  applies  to  an  older  product. 
(Allen  Thompson,  in  the  Edinburgh  Med.  and  Surg.  Journal,  vol.  lii.  p. 
122.)    Ovules  of  eleven  day?  were  the  youngest  observed  by  M.  Velpeau. 


OF    CONCEPTION".  123 

After  the  exit  of  the  ovule,  the  Graafian  vesicle  soon  retracts  upon  itself, 
and  thus  contributes  to  the  formation  of  the  corpus  luteum  before  spoken 
of  (p.  96). 

We  shall  hereafter  describe  the  modifications  which  the  ovule  undergoes 
during  its  passage  through  the  tube,  and  after  its  arrival  in  the  uterus. 

Conception  is  an  act  that  takes  place  unconsciously,  and  altogether 
involuntarily ;  although  some  females,  more  especially  those  who  have  had 
children,  imagine  that  they  can  distinguish  a  prolific  connection  from 
others.  They  say  a  much  more  voluptuous  sensation  is  then  experienced, 
a  spasm  much  better  marked  ;  and  I  have  met  with  too  many  females  who 
acknowledged  having  made  this  observation,  not  to  believe  there  is  some 
truth  in  the  assertion. 

The  same  ignorance  that  prevails  as  to  the  causes  of  fecundation,  like- 
wise exists  with  regard  to  those  opposing  its  accomplishment.  For,  though 
vices  of  conformation  or  faulty  position  of  the  uterus,  as  also  obliterations 
of  the  neck  or  tubes,  may  explain  the  sterility  of  some  individuals,  it  is 
wholly  impossible  to  understand  why  some  women  are  barren,  although  well 
formed  —  why,  in  a  considerable  number  of  cases,  married  females  have  not 
had  children  during  their  first  marriage,  whereas  they  subsequently  became 
pregnant,  when  even  it  has  been  observed  that  the  first  husband  had  chil- 
dren by  a  former  bed. 

The  period  at  which  fecundation  is  most  likely  to  take  place,  appears  to 
be  that  immediately  following  the  flow  of  the  menses ;  thus  M.  Raciborsky 
has  ascertained  that  the  conception  took  place  a  little  before  or  after  their 
appearance,  in  fifteen  females,  who  could  designate  precisely  the  time  of  the 
sexual  approach.  It  is  indeed  evident,  that  everything  seems  admirably 
prepared  at  this  period  for  the  reproduction  of  the  species;  but  I  am  far 
from  concluding,  as  M.  Raciborsky  has  done,  that  the  aptitude  for  fecunda- 
tion in  the  human  race  is  limited  to  a  few  days,  either  preceding  or  following 
the  menstrual  terms.  Experience  has  convinced  me  that  sexual  inter- 
course may  be  fruitful,  even  when  it  takes  place  in  the  middle  of  the 
interval  between  the  two  menstrual  epochs.  In  this  case  it  is  probable 
that  the  excitation  produced  by  coition  may  be  communicated  to  the 
ovarian  vesicles,  and  cause  modifications  in  them  altogether  similar  to  those 
experienced  in  the  menstrual  evolution ;  the  fact  itself  appears  to  me  to  be 
settled  beyond  a  doubt.1 

1  M.  Coste,  who  also  admits  the  possibility  of  conception  without  regard  to  the 
period  at  which  copulation  takes  place,  is  prepared,  he  says,  to  demonstrate  by  undeni- 
able proofs,  that  the  ovum  detached  from  the  ovary  during,  or  towards  the  close  of 
menstruation,  loses  all  capacity  for  fecundation  within  a  very  tew  days  after  being  set 
free.  Conception  is,  therefore,  only  possible  at  other  times  than  near  or  during  the 
menstrual  epochs,  when  other  circumstances  happen  to  produce  in  the  ovary  an  opera- 
tion similar  to  that  which  takes  place  at  the  period  of  heat.  Now  is  this  possible? 
Comparative  physiology  rep'ies  in  the  affirmative,  by  demonstrating  it  to  be  so  as 
regards  certain  animals,  thus  rendering  it  at  least  very  probable  for  the  lminan  species 
also. 

In  animals  living  in  the  savage  state,  says  the  learned  professor  of  the  College  of 
France,  the  ovaries  accomplish  their  functions  only  at  rue  intervals;  but  wLen 
iomesticated,  the  maturation   of   the  eggs  may  become  so  frequent  in  certain  species. 


124  PREGNANCY. 

I  shall  not  undertake  to  refute  the  opinion  of  those  who  believe  that 
either  sex  can  be  created  at  will ;  yet  I  think  it  not  improbaDle  that  the 
physical  constitution  of  the  husband  or  of  the  wife  may  have  some  influence 
in  determining  the  sex  of  the  child.  The  admirable  observations  of  M. 
Girou  seem  to  me  to  have  proved  that  with  the  inferior  animals,  at  least, 
the  stronger  the  male  is  in  comparison  with  the  female,  the  greater  is  the 
chance  of  producing  a  male,  and  vice  versa.  The  observations  I  have  been 
able  to  make  on  the  human  family  since  reading  the  statistical  results  of  M. 
Girou,  have  generally  confirmed  their  conclusions. 

Here  terminates  what  I  had  proposed  to- say  in  reference  to  fecundation. 
It  will  be  seen  that  I  have  limited  it  to  a  very  brief  exposition  of  the  most 
generally  received  views  of  this  point  of  physiology.  The  size,  and  espe- 
cially the  object  of  the  work,  seem  necessarily  to  exclude  more  ample 
details. 

that  the  ovulation  occurs  almost  daily  Thus  the  wild  pigeon,  which  deposits  her  eggs 
but  once  or  twice  a  year,  sets  seven  or  eight  times,  when  she  takes  up  her  abode  in 
our  dove-cotes.  Under  the  influence  of  an  appropriate  nourishment,  our  domestic 
fowls  lay  almost  every  day  for  eight  months  in  the  year.  The  rabbit  of  the  fields  brings 
forth  but  once  or  twice  yearly,  whilst  living  at  large;  but  in  the  domestic  conditi<m, 
she  will  reproduce  as  often  as  seven  times,  if  care  be  taken  to  wean  the  young  at  the 
proper  moment. 

There  are  therefore  conditions  of  shelter,  of  temperature,  and  of  alimentation,  which, 
by  acting  on  the  organism  of  animals,  may  cause  their  ovaries  to  exercise  their  func- 
tions more  frequently  in  a  given  space  of  time.  To  this  it  may  be  added,  that  in 
mammalia,  the  cohabitation  of  the  males  is  one  of  the  most  active  accelerating  causes 
of  the  dehiscence  of  the  vesicles.  Thus,  for  example,  a  female  rabbit  when  placed 
alone  in  a  cage  where  she  is  completely  protected  from  the  attempts  of  the  male,  enters 
ordinarily  into  heat  about  every  two  months,  and  when  the  time  of  this  periodic 
excitement  is  past,  she  refuses  obstinately  to  submit  to  coition;  but  if,  instead  of  sepa- 
rating her  from  the  male,  whom  she  then  repels  with  violence,  he  be  allowed  to 
remain  with  her  for  a  few  days  only,  it  may  be  regarded  as  certain  that  she  will  not 
resist  long,  because  the  solicitations  to  which  she  will  be  incessantly  subjected  will 
provoke  the  return  of  a  condition  which,  in  the  absence  of  this  excitement,  would 
have  been  much  longer  in  appearing. 

There  are,  therefore,  natural  and  entirely  spontaneous  periods  for  the  maturation 
and  discharge  of  ova,  and  there  are  also  others  which  may  be  styled  artificial,  because 
it  is  possible  to  produce  them  through  the  means  of  external  agents. 

Now,  is  it  possible  to  suppose  that  the  human  female,  who  commands  all  these  con- 
ditions at  her  will,  is,  by  an  inexplicable  exception,  inclosed  within  the  impassible 
boundaries  of  her  menstrual  periods?  And  if,  in  spite  of  her  first  vigorous  resistance 
to  the  attempts  of  the  male,  the  rabbit  finally  yields  to  the  influence  of  his  companion- 
ship, why  in  woman,  who  of  all  the  females  of  the  mammalia  is  endued  with  the  most 
constant  readiness  for  coition,  should  not  the  sexual  allurements  have  the  same  result? 

This  accidental  evolution  of  a  vesicle  is  not  followed  by  the  menstrual  flow  which 
ordinarily  accompanies  it ;  all  which  is  very  comprehensible,  for  we  must  not  forget 
that  the  same  cause  which  provokes  the  discharge  of  the  ovule,  is  also  that  which 
fecundates  it,  and  that  in  doing  so,  it  arrests  the  tendency  to  hemorrhage  before  it 
has  time  tj  appear.  (Coste,  Histoire  generate  et  particuliere  du  developpement  des  corpt 
■organises.)  The  same  thing,  in  fact,  happens  when  fecundation  oc  ;urs  a  few  days  01 
•»ours  only  before  the  appearance  of  the  menses. 


ORGANIC    CHANGES    DURING    PREGNANCY. 


125 


CHAPTER    II. 

CHANGES    IN   THE    MATERNAL    ORGANISM    DURING    PREGNANCY. 

A.  deep  impression  is  produced  upon  the  maternal  organism  by  the  preg- 
nant condition,  giving  rise  to  important  anatomical  and  functional  alterations. 


ARTICLE    I. 

ANATOMICAL   CHANGES    IN   THE    UTERUS. 

The  uterus  undergoes  remarkable  changes,  and  we  shall  commence  our 
description  with  them. 

These  modifications  may  either  be  in  the  volume,  form,  situation,  direc- 
tion, and  relations  of  the  womb ;  hence,  on  account  of  their  great  impor- 
tance, we  shall  successively  study  them  in  the  body  and  in  the  neck ;  then 
we  will  point  out  the  changes  which  the  structure  of  the  organ  undergoes. 

§  1.  Changes  in  the  Body  of  the  Uterus. 

a.  Volume. —  We  have  already  learned  that  under  the  influence  of  the 
hemorrhagic  congestion  which  the  uterus  undergoes  at  each  menstrual  period, 
the  bulk  of  the  organ  is  increased.  If  conception  takes  place  within  a  few 
days  preceding  or  following  the  flow  of  the  blood,  the  excitement  produced 
by  the  fruitful  coition  maintains,  and  soon  increases  the  hypertrophy  of  its 
walls.  Thus,  we  shall  find  further  on  (see  Deeidua),  that  the  mucous  mem- 
brane especially  becomes  almost  doubled  in  thickness,  so  that  when  the 
fecundated  ovule  arrives  in  the  cavity  of  the  womb,  it  finds  it  entirely  filled 
with  the  membrane,  which  is  swollen  to  such  an  extent  as  to  be  thrown  into 
folds  from  want  of  room  to  develop  itself.     (See  page  95.) 

The  same  thing  precisely  occurs  in  those  exceptional  cases  in  which  fecun- 
dation takes  place  some  time  from  the  menstrual  period.  Here  the  hyper- 
trophy also  begins  under  the  influence  of  the  evolution  of  a  Graafian  vesicle ; 
only  the  evolution,  instead  of  being  spontaneous,  is  the  result  of  a  more  or 
less  prolonged  venereal  excitement. 

As  soon  as  the  ovule  arrives  in  the  womb,  the  latter  begins  to  develop, 
and  its  volume  continues  to  increase  until  the  end  of  pregnancy ;  but  thia 
progression  is  not  uniform,  for,  according  to  the  observations  of  Desormeaux, 
it  is  much  slower  in  the  early  months,  and  more  rapid  in  the  latter.  An 
accurate  idea  of  this  increase  may  be  formed  from  the  following  table,  which 
represents  the  usual  dimensions  of  the  uterus  at  the  principal  periods  of 
pregnancy. 


Vertical  Diameter. 

Trahsvirse. 

AXTERO-l'OBTERIOR. 

Third  month,    .     .     . 
Fourth      "         .... 
Sixth         "              .     . 
Ninth        "         ... 

2$         inches. 

8| 
12J  to  14£     " 

2'j  inches. 

9A      " 

2|     inches. 

:;;         » 

GJ         « 

83  to  9\     " 

120  PREGNANCY. 

The  development  of  the  uterine  walls  is  not  purely  mechanical,  jm  haa 
been  supposed,  nor  is  their  distention  the  result  of  the  development  of  the 
ovum,  which,  by  pressing  upon  the  different  points  of  the  internal  surface, 
would  tend  to  separate  them  more  and  more. 

W  we  consider  the  small  volume  of  the  ovule  in  the  first  weeks  of  preg« 
nancy,  as  compared  with  the  thickness  of  the  walls  of  the  uterus  at  the  same 
period,  we  shall  not  fail  to  be  convinced  that  the  expansive  force  of  the 
ovum  would  be  unable  to  overcome  their  resistance.  The  development  of 
the  ovum  and  that  of  the  uterus  are  simultaneous,  but  effected  by  forces 
which  are  inherent  in  each  ;  in  a  word,  the  growth  of  the  ovum  acts  as  a 
physiological  cause,  but  not  as  a  mechanical  agent  in  the  development  of 
the  walls  of  the  uterus. 

B.  Shape. — The  shape  of  the  uterus  changes  simultaneously  with  the 
alteration  in  its  volume.  Being  flattened,  at  first,  on  its  two  faces,  the 
womb  grows  rounder  and  soon  becomes  pyriform,  then  spheroidal,  and 
towards  the  end  of  pregnancy  it  has  the  form  of  an  ovoid,  which  is  slightly 
flattened  from  before  backwards.  The  anterior  face,  however,  is  much  the 
more  convex,  and  the  posterior  one  is  depressed,  so  as  to  accommodate 
itself  to  the  prominence  of  the  lumbar  vertebra?. 

At  the  end  of  pregnancy,  the  superior  extremity  of  the  uterine  ovoid  is 
quite  regularly  rounded  ;  that  side  of  the  fundus,  however,  which  is  occupied 
by  one  of  the  extremities  of  the  foetal  ovoid,  being  often  more  elevated  than 
the  other,  which  is  filled  with  fluid  only.  Now,  as  in  the  most  usual  pres- 
entations, the  trunk  of  the  foetus  is  generally  inclined  towards  the  right, 
the  right  side  of  the  fundus  of  the  uterus  is  commonly  the  most  elevated. 
(Hergott.)  Sometimes  both  sides  are  alike  in  this  respect,  and  there  is  a 
depression  upon  the  middle  and  upper  part  of  the  organ. 

Such  is  the  shape  of  the  uterus  in  the  majority  of  cases  ;  but  the  situation 
and  number  of  the  foetuses,  and  the  structure  and  primitive  form  of  the 
organ,  may  produce  important  changes  in  the  shape  which  it  assumes  during 
gestation ;  and  which  will  claim  our  attention  hereafter. 

C.  Situation. — It  is  evident  that  the  uterus  cannot  thus  change  in  shape 
and  size,  without  undergoing  a  simultaneous  alteration  in  its  position  ;  for 
example,  during  the  first  three  months  of  gestation,  the  womb  remains 
sunken  in  the  excavation,  but  as  the  volume  increases  in  all  directions,  the 
fundus  of  the  organ  rises  towards  the  superior  strait,  whilst  its  inferior  part 
and  neck  subside  still  more  towards  the  floor  of  the  pelvis.  This  depression 
of  the  organ  is  produced  by  its  yielding  to  the  laws  of  gravitation  from  its 
:>wn  increased  weight,  as  also  by  the  augmented  pressure  of  the  intestinal 
mass  upon  the  larger  surface,  created  by  the  change  in  the  fundus.  Hence, 
both  its  increase  of  volume  and  its  weight,  augmented  by  the  pressure  of 
the  intestinal  mass,  which  now  has  an  extensive  point  oVappui  on  the  fundus, 
contribute  to  produce  the  first  change  in  position. 

At  the  same  time,  the  uterus  remains  in  the  sacral  cavity  from  the  greater 
space  found  there,  and,  the  fundus  being  turned  a  little  backwards,  causes 
the  neck  to  advance  slightly.  Besides,  the  presence  of  the  rectum  on  the 
left  most  generally  obliges  the  organ  to  deviate  towards  the  right,  and  the 
neck,  in  a  corresponding  manner,  to  the  left;  consequently,  during  the  first 


ORGANIC   CHANGES    DURING    PREGNANCY.  127 

three  months,  the  cervix  is  directed  downwards,  forwards,  and  a  little  to 
the  left. 

About  the  third  month  and  a  half,  or  the  fourth  month,  the  uterus,  no 
longer  finding  sufficient  room  in  the  excavation  for  its  continued  develop- 
ment, rises  above  the  superior  strait,  then  to  the  level  of  the  umbilicus,  and 
reaches  the  epigastric  region  towards  the  end  of  pregnancy. 

In  tracing  out  the  gradual  elevation  of  the  fundus  uteri,  it  will  be  found, 
at  the  fourth  month,  to  rise  two  or  three  fingers'  breadth  above  the  pubis ; 
at  five  months,  it  is  within  one  finger's  breadth  of  the  umbilicus ;  and  from 
the  fifth  to  the  sixth  month,  it  approaches  and  passes  the  umbilical  depres- 
sion, so  that  at  six  months  it  is  half  an  inch  above  this  ring ;  three  fingers' 
breadth  at  seven  months;  and  four  to  five  at  eight  months;  it  still  continues 
ascending  in  the  commencement  of  the  ninth,  but  in  the  last  fortnight  of 
gestation,  the  womb  seems  to  sink  down,  being,  in  fact,  on  a  lower  level 
than  before.  This  last  is  a  remarkable  occurrence,  though  it  has  been  said 
in  explanation  that  the  uterus,  as  if  overburdened  with  the  weight  of  the 
foetus  during  the  latter  period,  collapses  to  some  extent,  and  enlarges  in  the 
transverse  and  the  antero-posterior  diameters.  This  may  be  true  as  regards 
some  females  who  have  previously  had  children,  for  not  unfrequently  they 
say  to  us  at  this  time,  "  It  has  all  gone  to  the  sides ;"  but  I  believe  a  more 
general  explanation  of  the  fact  may  be  given ;  for,  in  the  great  majority  of 
cases,  if  females  be  "  touched  "  near  the  end  of  pregnancy,  a  voluminous 
tumor,  covered  by  the  inferior  and  more  especially  by  the  anterior  part  of 
the  uterine  body,  will  be  readily  felt  occupying  the  excavation.  This  is  the 
head  of  the  foetus,  which  has  descended  in  consequence  of  its  own  weight, 
carrying  the  wall  of  the  uterus  before  it,  and  become  engaged  in  the  excava- 
tion, sometimes  even  as  low  down  as  the  floor  of  the  pelvis. 

Now,  does  not  this  circumstance,  which  may  be  remarked  whenever  the 
head  presents  regularly,  and  when  there  is  no  malformation  of  the  pelvis, 
furnish  us  a  sufficient  reason  for  the  depression  of  the  entire  uterus?  How, 
in  fact,  could  the  superior  do  other  than  follow  the  inferior  part  of  the  organ  ? 

D.  Direction.  —  In  passing  up  into  the  abdominal  cavity,  the  uterus  is 
obliged  to  follow  the  direction  of  the  axis  of  the  superior  strait,  and  being 
thrown  off  by  the  lumbar  column,  and  finding  much  less  resistance  from  the 
anterior  abdominal  wall,  it  necessarily  inclines  forward  ;  but,  owing  to  the 
lumbar  projection,  it  cannot  possibly  remain  on  the  median  line,  and  hence 
it  leans  towards  one  side  of  the  abdomen,  the  right  one,  remarkable  as  it 
may  seem,  at  least  eight  times  in  ten. 

Most  authors,  since  the  days  of  Levret,  have  endeavored  to  explain  this 
great  frequency  of  the  right  lateral  obliquity.  Levret  himself  taught,  that 
the  uterus  always  inclines  towards  the  side  where  the  placenta  is  inserted ; 
for  this  point,  he  said,  being  the  thickest  and  most  vascular  part  of  the 
whole  organ,  is  also  the  heaviest,  and  this  increased  weight  augmented  by 
that  of  the  placenta,  must  necessarily  draw  the  organ  to  that  side;  but 
experience  has  shown  that  the  placenta  is  far  from  being  always  inserted 
on  the  one  side  towards  which  the  uterus  is  inclined.  Again,  according  to 
Desormeaux,  the  presence  of  the  iliac  portion  of  the  colon,  which  is  usually 
filled  with  fecal  matter,  prevents  the  womb  from  leaning  to  the  left,  when 


I 

128  PREGNANCY. 

it  commences  ascending  out  of  the  excavation,  and  thrusts  into  the  rignt 
iliac  fossa,  whilst  the  mass  of  the  small  intestines  is  pushed  to  the  left  side 
by  the  ascent  of  the  womb  (where  the  direction  of  the  mesentery  would 
naturally  draw  them),  and  this  assists  both  to  maintain  and  to  increase  the 
inclination  of  the  uterus  to  the  right.  But,  as  M.  Paul  Dubois  has  justly 
remarked,  any  influence  which  the  colon,  placed  on  the  left,  may  have,  is 
fully  compensated  by  the  presence  of  the  ccecum  on  the  right ;  and,  from 
the  observation  of  M.  Velpeau,  the  mesentery  is  directed  from  left  to  right, 
and  not  from  right  to  left  as  Desormeaux  has  it,  doubtless  by  mistake. 

The  habit  of  using  the  right  arm,  and  of  lying  upon  the  right  side,  has 
also  been  brought  forward  in  explanation  of  this  right  lateral  obliquity,  but 
subsequent  observation  has  not  sustained  the  assertion ;  thus,  for  instance, 
in  seventy-six  females,  all  of  whom  had  the  uterus  inclined  to  the  right, 
thirty-eight  rested  on  the  right  side,  twenty  on  the  left,  fourteen  alternately 
on  both  sides,  and  four  on  the  back.  And  we  may  further  remark  that, 
down  to  the  present  time,  it  has  not  been  observed  that  the  uterus  is  placed 
upon  the  left  side  of  the  abdomen  more  frequently  in  those  women  who 
habitually  use  the  left  arm  than  in  others. 

Madame  Boivin  has  given  an  entirely  different  explanation  of  this  fact ; 
she  asserts  that  the  round  ligament  of  the  right  side  is  shorter,  stronger,  and 
contains  more  muscular  fibres  than  that  of  the  left,  and  she  attributes  tho 
right  inclination  of  the  organ  to  the  more  powerful  action  of  this  ligament. 

Professor  Cruveilhier  thinks  that  the  shortness  of  the  round  ligament  on 
the  right,  is  the  effect  and  not  the  cause  of  the  uterine  obliquity ;  "  for  I 
have  frequently  had  occasion,"  he  remarks,  "to  observe  that  the  shortening 
which  occurred  on  the  left,  in  left  lateral  obliquity,  was  constantly  accom- 
panied by  a  remarkable  increase  of  volume."  I  must  confess  that  I  do  not 
comprehend  upon  what  M.  Cruveilhier  founds  this  opinion. 

[In  order  to  test  Madame  Boivin's  explanation,  M.  Pajot,  in  connection  with  Dr 
Rambaud,  former  prosector  to  the  hospitals,  undertook  new  measurements  of  the 
length  of  the  two  round  ligaments. 

From  their  investigations  it  would  appear,  that  even  in  women  who  have  been 
delivered,  the  left  round  ligament  is  not  so  often  the  longer  as  has  been  supposed, 
and  more  especially  is  this  greater  length  far  less  common  than  the  right  lateral 
inclination  of  the  womb  during  pregnancy. 

All  the  explanations  of  the  fact  being  then  so  unsatisfactory,  M.  Pajot  comes  to 
the  conclusion  that  the  inclination  of  the  pregnant  uterus  is  due  to  the  mode  of 
evolution  of  the  organ  itself. 

Beside  this  lateral  inclination,  the  entire  womb  undergoes  a  rotation  upon  its 
axis,  which  carries  its  anterior  surface  a  little  to  the  right,  whilst  the  posterior 
surface  looks  backward  and  to  the  left. 

From  this  it  results,  that,  if  during  an  autopsy  the  abdominal  parietes  be 
removed  without  disturbing  the  womb,  the  annexes  of  the  uterus  and  the  ovary  of 
the  left  side  are  found  in  front,  whilst  the  same  parts  belonging  to  the  right  side 
are  concealed  behind  near  the  right  sacro-iliac  symphysis.] 

E.  Relations. — At  term,  the  uterus  is  in  relation  —  1.  In  front,  with  the 
vagina,  the  posterior  face  of  the  neck  and  body  of  the  bladder,  and 
mperiorly,  with  the   anterior   abdominal   wall.     This  last  is  not  always 


ORGANIC     CHANGES     DURING     PREGNANCY.  129 

immediate,  for  occasionally  a  portion  of  the  intestinal  mass  slips  between 
the  uterus  and  the  ventral  parietes,  as  occurred  in  the  woman  upon  whom 
M.  Dubois  practised  the  Cesarean  operation  in  1839;  and,  as  the  professor 
has  remarked,  the  operator  should  be  very  prudent  in  making  his  incisions, 
from  the  possibility  of  encountering  this  anomaly.  2.  Behind,  with  the 
rectum,  sacro-vertebral  angle,  and  vertebral  column  below,  and  with  the 
mesentery  and  intestinal  mass  above.  3.  On  the  right,  with  the  correspond- 
ing side  of  the  pelvis,  the  iliac  vessels,  psoas  muscles,  coecum,  and  right 
abdominal  wall.  4.  On  the  left,  with  that  part  of  the  pelvis,  the  iliac 
vessels  and  aorta,  the  sigmoid  flexure,  the  psoas  muscles,  and  the  whole 
body  of  intestines  which  separate  it  from  the  abdominal  wall. 

F.  Thickness  of  the  Parietes. — The  earlier  authors  on  this  subject  enter- 
tained very  different  views  concerning  it:  some,  judging  the  thickness  of 
the  body  by  that  of  the  neck  during  labor,  concluded  that  the  uterus  could 
not  be  distended  without  a  great  diminution  in  the  depth  of  its  walls; 
others,  having  had  better  opportunities  of  examining  the  wombs  of  females 
who  died  soon  after  the  accouchement,  observed  the  very  considerable 
thickness  exhibited  by  the  uterine  parietes  at  that  time,  and  therefore 
adopted  the  opinion  that  the  latter  become  much  thicker  during  gestation. 

Both  sides  were  in  error,  for  numerous  autopsies,  made  since  that  period, 
of  women  who  died  during  gestation,  have  established  the  truth  of  the 
following  propositions,  namely: 

1.  In  the  three  first  months,  the  uterine  walls  augment  a  little  in  thick- 
ness, doubtless  in  consequence  of  the  development  of  their  vascular  and 
muscular  apparatus.  2.  Towards  the  fifth  month,  they  are  about  the  same 
as  in  the  normal  state,  3.  At  term,  the  parietes  are  thicker  than  in  the 
natural  condition,  at  the  point  corresponding  to  the  insertion  of  the  placenta, 
thinner  at  the  neck,  and  they  present  but  very  little  difference  throughout 
the  remainder  of  their  extent. 

We  may  here  notice  some  further  exceptions:  thus,  M.  Moreau,  having 
measured  the  thickness  of  the  walls  in  a  woman  deceased  at  term,  found  it 
one-sixth  of  an  inch  at  the  fundus,  one-fourth  of  an  inch  at  the  insertion  of 
the  placenta,  and  one-third  of  an  inch  at  the  neck.  This  singular  anomaly 
may  be  explained,  says  M.  Moreau,  1st,  as  regards  the  thinness  of  the  fundus, 
by  the  enormous  distention  the  uterus  had  undergone  (being  a  twin  preg- 
nancy). And  2d,  the  greater  thickness  of  the  neck  resulted  from  the  con- 
siderable retraction  this  part  had  sustained  from  the  escape  of  the  amniotic 
liquid  before  death. 

In  one  instance,  Saviard  found  it  one-third  of  an  inch  at  the  placental 
attachment,  and  only  a  line  in  other  parts. 

My  friend,  Dr.  Iiipault,  in  performing  the  Cesarean  operation,  found 
the  uterine  wall  only  one  or  two  lines  thick. 

[At  an  autopsy  made  near  the  end  of  pregnancy,  I  found  the  walla  of  the  uterus 
remarkably  thin,  from  T'y  to  -pv  of  an  inch,  throughout  the  greater  part  of  their 
extent;  M.  NAlaton,  who  was  present,  confirming  the  observation.  This  thinning 
is,  therefore,  not  very  unusual,  and  I  am  even  inclined  to  think  is  the  most  frequent 
condition. 

la  many  pregnant  women,  the  parts  of  the  child  may  be  felt  very  easily;  in  some 
y 


130  PREGNANCY. 

eases  the  hand  appearing  to  bo  separated  from  them  by  a  layer  of  but  a  few  lines 
in  thickness.  Notwithstanding  all  this,  it  is  nevertheless  true  that  the  entire  bulk 
of  the  uterine  walls  undergoes  considerable  increase  during  gestation  in  consequenee 
of  the  great  extension  in  surface. 

To  prove  this,  it  is  only  necessary  to  weigh  the  uterus  of  a  woman  dead  at  the 
end  of  her  pregnancy,  when  it  will  be  found  that  the  weight  of  the  organ,  after 
separation  from  the  neighboring  parts  and  removal  of  its  contents,  will  vary  from 
three  to  almost  four  pounds.  In  the  case  of  M.  Moreau,  above  cited,  it  was  nearly 
four  pounds. 

The  uterus,  therefore,  increases  at  least  twenty  times  in  weight  during  preg 
nancy,  a  fact  surely  sufficient  to  prove  the  occurrence  of  hypertrophy  under  these 
conditions.] 

Again,  the  thinness  may  be  partial ;  thus  Hunter  describes  a  uterus,  the 
posterior  walls  of  which  exhibited  this  phenomenon  in  a  remarkable  degree. 

G.  Density  of  the  Walls.  —  The  uterine  parietes,  in  the  non-gravid  state, 
are  very  hard  and  resisting,  and  have  nearly  the  consistence  of  fibrous 
tissue,  but  during  pregnancy  this  density  diminishes  and  the  walls  become 
soft  and  flabby.  The  ramollissement  begins  to  show  itself  as  early  as  the 
first  month,  and  constitutes  at  that  period  one  of  the  best  signs  for  proving 
a  commencing  pregnancy  (see  article  on  Diagnosis),  because,  instead  of 
presenting  the  fibrous  density  of  the  ordinary  state,  the  walls  have  a 
clammy  softness  closely  resembling  that  of  caoutchouc  softened  by  ebul- 
lition, or  that  of  an  oedematous  limb.  This  decrease  in  the  consistence  of 
the  uterine  walls  constantly  advances,  so  that,  at  a  later  period,  a  light 
pressure  made  on  the  anterior  abdominal  parietes  will  easily  depress  or 
deform  them ;  consequently,  the  extremities  and  other  inequalities  of  the 
foetus  may  be  detected,  and  its  movements  may  even  cause  an  elevation  of 
some  part  or  other;  the  child,  therefore,  is. not  placed  in  a  cavity  having 
immovable  walls. 

The  diameters  of  this  cavity  will  vary  with  the  position  taken  by  the 
foetus,  which  can,  in  some  cases,  continue  to  chauge  them  until  the  end  of 
gestation,  the  flexibility  of  the  walls  permitting  its  long  diameter  to  pass 
through  the  small  ones  of  the  organ  ;  and  we  can  readily  comprehend  how 
this  flexibility,  this  suppleness  of  the  fibres  of  the  womb,  will  aid  in  pre- 
venting the  disastrous  consequences  which  otherwise  might  result  to  the 
child  from  any  violent  blows  on  the  abdomen,  or  from  the  shocks  expe- 
rienced by  the  mother. 

§  2.  Modifications  in  the  Neck  of  the  Uterus. 

The  modifications  which  the  neck  undergoes  during  pregnancy,  arc 
referable:  1,  to  the  consistence  of  its  tissue;  2,  its  volume;  3,  its  form; 
4,  its  situation  and  direction. 

1.  As  the  softening  of  the  tissue  of  the  neck  of  the  uterus  seems  to  be  an 
all-important  fact,  we  therefore  give  it  the  first  place. 

Now,  everybody  knows,  that,  in  the  non-gravid  state,  the  uterine  tissue 
resembles  the  fibrous  in  its  consistence;  but  immediately  after  conception, 
and  from  the  sole  fact  of  the  active  congestion  which  the  genital  organs 
then  experience,  this  consistence  begins  to  diminish,  although,  from  being 
coincident  with  the  hypertrophy  of  the  uterine  walls,  it  is  scarcely  sensible 


ORGANIC    CHANGES    DURING    PREGNANCY.  131 

during  the  first  few  days,  whatever  may  be  the  extent  of  the  neck  exam- 
ined. But  towards  the  end  of  the  first  month  we  may  ascertain  that,  inde- 
pendently of  this  original  general  modification,  the  most  inferior,  or  rather, 
the  most  superficial  part  of  the  lips  of  the  os  tincse,  begins  to  soften.  It 
resembles  more  a  swelling  of  the  mucous  membrane  than  a  true  "ramol- 
lissement"  of  the  proper  tissue  of  the  lips;  so  that  by  pressing  slightly  on 
this  thickened  membrane  the  finger  first  detects  a  fungous  softness,  but  soon 
reaches  the  proper  tissue  of  the  neck,  which  still  maintains  its  normal 
consistence.  The  sensation  then  experienced  by  the  finger  greatly  resem- 
bles that  communicated  when  it  is  pressed  on  a  table  covered  by  a  soft  and 
thick  cloth,  or,  better  still,  a  sheet  of  India-rubber ;  and  it  is  only  towards 
the  end  of  the  third,  or  beginning  of  the  fourth  month,  that  the  lips  of  the 
os  tincse  are  softened  throughout  their  Avhole  thickness  to  the  extent  of  a 
line  or  a  line  and  a  half. 

At  the  commencement  of  the  fifth,  the  softening  increases  from  below 
upwards,  and  at  the  sixth  embraces  the  moiety  of  the  sub-vaginal  portion. 
During  the  last  three  months  it  invades  the  superior  part  by  degrees,  and 
last  of  all  the  ring  of  the  internal  orifice,  so  that,  at  the  end  of  gestation, 
the  neck  is  so  soft  in  certain  females,  that  I  have  frequently  seen  students 
have  great  difficulty  in  distinguishing  it  from  the  walls  of  the  vagina. 

This  modification  of  the  neck,  which  authors  have  scarcely  spoken  of,  is 
one  of  the  most  important  signs  ;  because,  after  a  little  experience,  it  affords 
us  one  of  the  best  means  for  ascertaining  the  different  stages  of  pregnancy ; 
being  constant,  and  found  in  all  females,  unless  the  neck  should  be  the 
seat  of  some  pathological  alteration.  It  is  worthy  of  notice,  however,  that 
the  softening  is  not  so  well  marked,  and  is  much  slower  in  its  progress  in 
primiparse,  than  in  women  who  have  previously  had  children ;  but  in  all,  it 
steadily  proceeds  from  below  upwards. 

A.s  before  remarked,  we  may  judge  very  nearly  of  the  probable  period 
of  pregnancy  by  the  extent  of  softening,  as  it  progresses  from  the  inferior 
to  the  superior  part  of  the  neck;  though  there  is  one  important  remark  to 
be  made  on  this  subject,  namely,  that  whenever  females  have  had  a  great 
number  of  children,  the  sub-vaginal  portion  of  th^  neck  loses  the  greater 
part  of  its  length ;  the  extremity  then  projecting  into  the  vagina,  and 
capable  of  exploration  by  the  finger,  being  much  shorter.  Now,  as  the 
softening  of  the  supra-vaginal  portion  of  the  neck  is  of  much  more  difficult 
detection,  it  may  be  thought  to  be  much  less  extensive  than  it  is  in  reality, 
whence  we  may  expect  to  find  a  great  difference  in  the  extent  of  the  soft- 
ened part,  if  a  comparsion  be  made  between  the  necks  in  two  females,  both 
advanced  to  the  sixth  month,  one  of  whom  is  pregnant  for  the  second  time, 
and  the  other  had  previously  borne  ten  children.  Wherefore  it  is  necessary, 
in  making  this  appreciation,  to  bear  in  mind  the  number  of  former  preg- 
nancies, as  also  the  real  length  of  the  sub-vaginal  portion   >f  the  cervix. 

2.  Volume. — Some  singular  idea-  on  thissubject  have  been  promulgated 
by  many  authors,  but  the  following  appears  to  be  the  mo^t  constant  rule: 
the  neck  doubtless  participates  in  the  hypertrophy  of  the  uterine  wails 
during  the  earlier  months,  though  its  development  is  far  less  considerable 
The  neck  becomes  thicker  and  grows  more  volumin  >us,  especially  at   th< 


132  PREGNANCY. 

superior  part,  but  I  have  never  observed  its  elongation  to  the  extent  of  two 
inches,  as  Madame  Bjivin  apparently  believes,  or  to  two  and  three-quarters 
and  throe  inches,  as  M.  Filugelli  has  more  recently  advanced ;  for,  aa 
elsewhere  observed,  these  opinions  result,  in  my  estimation,  from  an  error. 
The  neck,  in  the  commencement,  being  much  lower,  and  directed  more  in 
front  than  in  the  ordinary  condition,  the  finger  can  easily  explore  a  larger 
extent  of  it,  and  thus  an  impression  is  created  of  an  increase  in  its  length 
which  really  does  not  exist;  for  frequent  post-mortem  examinations  cf 
females  who  died  in  the  early  months  of  pregnancy,  have  convinced  me 
that,  even  if  the  neck  is  increased  in  thickness,  its  length  does  not  undergo 
any  appreciable  augmentation. 

At  the  commencement  of  the  fifth  month,  according  to  most  writers,  the 
cervix  begins  to  diminish.  In  the  sixth  month  (they  say)  it  begins  to  spread 
out  at  the  superior  part,  so  as  to  aid  in  the  enlargement  of  the  body  of  the 
womb,  and  tins  spreading  at  the  upper  part  continues  to  advance  in  pro- 
portion as  the  term  of  gestation  approaches,  and  consequently  the  length 
of  the  neck  decreases  from,  above  downwards,  so  as  merely  to  present  at 
last,  at  the  close  of  the  ninth  month,  a  ring  of  variable  thickness.  In  fact, 
the  diagnosis  of  the  different  periods  was  based  on  this  gradual  shortening, 
and,  agreeably  to  the  majority  of  the  French  accoucheurs  who  have  adopted 
the  opinions  of  Desormeaux,  the  neck  has  lost  at  the  fifth  month  about 
one-third  of  its  length,  one-half  at  the  sixth,  two-thirds  or  three-quarters 
in  the  seventh,  three-fourths  or  four-fifths  in  the  eighth,  and  the  remainder 
is  effaced  during  the  course  of  the  ninth  month  ;  and  yet,  I  do  not  hesitate 
to  pronounce  all  this  an  entire  error,  which  was  first  pointed  out  by  M.  Stoltz, 
in  1826,  and  to  which  I  also  have  constantly  asked  attention  since  the  year 
1839.  No ;  the  neck  does  not  shorten  in  the  way  which  has  so  long  been 
described;  it  preserves  its  whole  length  until  the  last  fortnight  of  preg- 
nancy ;  and  it  is  an  easy  matter,  especially  in  women  who  have  previously 
borne  children,  to  verify  this  remark,  as  we  shall  presently  demonstrate. 
But  during  the  last  few  weeks,  its  length,  which  until  that  time  was  intact, 
diminishes  very  rapidly,  and  even  disappears  by  a  total  effacement ;  and 
we  shall  in  due  season  explain  the  simple  mechanism  of  this  phenomenon. 
But  to  return  ;  I  have  frequently  been  enabled  to  prove,  in  primiparoo,  the 
truth  of  M.  Stoltz's  assertions ;  for  in  these  women  the 
neck  does  diminish  a  little  in  length,  during  the  last  three 
months,  although  by  a  process  entirely  different  from  that 
described  by  Desormeaux.  Thus,  towards  the  seventh 
month,  the  ramollissement  has  invaded  the  whole  intra- 
vaginal  portion  ;  the  parietesof  the  neck,  having  lost  their 
consistence,  are  easily  separated  by  the  liquids  secreted 
upon  their  internal  face,  and  the  upper  part  of  this  por- 

i  sei'tiuii,  showing  the      ...  .         ,  ,  i  •  i 

„cck  of  the  ntenw;  the  tion  being  turned  outwards,  enlarges  in  such  a  mannei 
»nterior  nnd  posterior  lips  ag  (()  cause  the  whole  neck  to  resemble  a  spindle  in  ita 
ii'".r  shape;  the  superior  extremity  of  which  is  formed  by  the 
by  the  fusiform  cavity  of  internal  orifice  (still  closed),  and  the  inferior  is  con- 
stituted by  the  external  one,  which  is  scarcely  opened  in 
]  rimipane,  even  at  the  end  of  gestation,  as  we  shall  hereafter  show 


ORGANIC     CHANGES     DURING     PREGNANCY. 


133 


Now,  it  is  easily  understood  how  this  bulging  of  the  middle  part  of  the  neck 
can  only  take  place  just  in  proportion  as  the  two  extremities  of  the  latter  ap- 
proach each  other  ;  thus,  of  course,  detracting  so  much  from  its  total  length. 
I  do  not  believe,  however,  with  M.  Stoltz,  that  the  approximation  of  the  two 
orifices  can  be  so  great  as  to  cause  a  material  shortening  of  the  neck,  though 
this  eertairly  does  exist  to  some  extent.  The  shortening  of  the  neck  is 
therefore  real,  though  slight,  in  primipane ;  being  accomplished,  however, 
by  a  different  mechanism  from  that  taught  by  most  authors.  Its  upper  part 
does  not  spread  out  so  as  to  contribute  to  the  enlargement  of  the  cavity  of 
the  body,  but  suffers  a  sort  of  collapse,  which  brings  the  two  orifices  nearer 
together,  at  the  same  time  increasing  its  central  cavity,  and  extending  its 
transverse  diameters  at  the  expense  of  the  vertical.  What  has  been  said 
concerning  the  rapid  effacement  of  the  neck  during  the  last  few  days  in 
multipara?,  equally  applies  to  primiparse  ;  the  process  taking  place  by  the 
same  mechanism. 

3.  Form.  —  The  principal  modifications  in  the  shape  of  the  neck  have 
already  been  presented,  but  they  ought  to  be  studied  in  a  more  special  man- 
ner, according  to  whether  they  are  found  in  prirni  parse,  or  in  women  who 
have  previously  been  mothers. 

A.  At  the  commencement,  in  primiparse,  the  cervix  appears  more  con- 
tracted and  more  pointed,  resulting,  perhaps,  from  the  augmentation  of  its 
superior  part  in  volume  ;  the  orifice  of  the  os  tincse,  which,  before  conception, 
presented  a  simple  linear  and  transverse  fissure,  now  assumes  a  circular 
form,  constituting,  as  it  were,  a  small  lenticular  fossa.  A  little  later,  as 
mentioned  above,  the  middle  part  of  the  cavity  of  the  neck  enlarges,  so  as 
to  give  to  the  whole  cervix  the  form  of  a  somewhat  elongated  spindle,  rather 
than  that  of  a  cone,  which  it  previously  had.  It  continues  smooth  and 
polished  on  the  exterior  surface,  and  the  periphery  of  its  orifice  is  rounded, 
without  any  irregularities  or  fissures;  sometimes  presenting  a  soft  circum- 
ference, at  others  a  thin  and  sharp  border:  the  latter  rarely  happens,  how- 
ever, before  a  very  advanced  stage.  At  this  time,  it  is  very  easy  to  ascertain 
what  changes  the  neck  has  undergone,  for  although  the  external  orifice  is 
constricted,  it  is  very  much  softened,  and  sometimes  allows  the  finger  to 
pass  with  a  very  slight  effort  and  enter  the  cavity  of  the  neck.  The  base 
of  the  last  phalanx  is  then  felt  to  be  grasped  quite  tightly  by  the  external 
orifice,  whilst  the  extremity  of  the  finger  is  at  full  liberty  in  the  fusiform 
cavity  of  the  neck.  It  may  also  be  readily  observed  that  the  two  orifices  are 
still  widely  separated,  for  the  entire  length  of  the  first  phalanx  and  some- 
times more,  are  capable  of  being  contained  in  the  cavity. 

Fig.  40.  Pio.  tl.  Fio.  42. 


Tlic-r  three  ftgui ua  give  ,"<  id 


if  tin'  gradual  dilatation  winch  ill 
vjiri hum  perlodu  of  preguuiicy. 


nciU  iimli'i  goes  at 


134  PREGNA.VCY. 

B.  The  form  of  the  neck  is  altogether  different  in  women  who  have  had 
ihildren  ;  thus  the  inequalities  and  protuberances  exhibited  by  the  inferioi 
part  will  scarcely  permit  us  to  ascertain  whether  it  becomes  more  pointed 
or  not,  and  it  is  equally  difficult  to  determine  whether  the  external  orifice 
has  become  more  rounded  ;  because,  having  been  somewhat  patulous  before 
pregnancy,  this  orifice,  in  consequence  of  the  numerous  cicatrices  found  on 
it,  presents  a  very  irregular  opening.  The  only  point  capable  of  demonstra- 
tion in  the  early  periods  is,  that  the  partially  opened  orifice  will  dilate  still 
further,  so  as  to  admit  readily  the  extremity  of  the  fore-finger. 

This  spreading  out  of  the  os  tinea;,  and  the  inferior  part  of  the  neck,  con- 
stantly increases  from  below  upwards,  as  the  gestation  progresses;  it  reaches 
the  middle  part  of  the  cervix  about  the  seventh  month,  and  nearly  gains 
the  internal  orifice  by  the  ninth. 

The  enlargement  of  the  cavity  of  the  neck  advances  simultaneously  with 
the  softening  of  its  walls  ;  and  we  can  easily  prove  by  experiment  that  the 
ringer  will  each  month  penetrate  deeper  into  it.  The  shape  of  this  cavity 
resembles  in  some  women  that  of  a  thimble,  in  others,  of  a  funnel,  with  the 
hase  below  and  the  apex  above,  the  difference  being  due  simply  to  the  depth 
and  number  of  the  ruptures  which  had  existed  on  the  external  orifice  before 
pregnancy. 

The  part  of  the  neck  not  yet  softened  and  dilated  constitutes  the  summit 
of  the  cone:  that  is,  every  portion  of  its  length  contributes  in  succession;  so 
that  the  first,  and  often  even  the  half  of  the  second  phalanx  of  the  finger 
can  penetrate  into  its  cavity  towards  the  ninth  month,  the  extremity  of  the 
finger  being  only  arrested  by  the  internal  orifice,  which  is  still  closed  and 
puckered  like  the  knot  of  a  purse.  The  ring  at  this  orifice  finally  softens, 
becomes  dilated,  and  permits  the  finger,  which  has  passed  through  a  canal 
an  inch  to  an  inch  and  a  half  in  length,  formed  by  the  cervix,  to  come  into 
direct  contact  with  the  naked  membranes.  If  the  length  of  the  external 
surface  of  the  neck  be  compared  at  this  period  with  the  canal  in  which  the 
finger  is  introduced,  the  neck  will  be  found  much  longer  internally  than 
exteriorly,  for  it  is  self-evident  that  the  finger  is  arrested  on  the  outside  by 
the  vaginal  insertion,  whilst  within  it  traverses  the  whole  space  between  the 
two  orifices. 

The  internal  orifice  sometimes  opens  too  soon;  thus  Desormeaux  declares 
that  he  touched  the  membranes  at  the  end  of  seven  months,  over  a  space  of 
an  inch  and  one-third  in  extent.  I  also  have  verified  the  same  fact,  but 
only  in  women  who  were  subject  to  floodings,  or  in  those  who  submit  to 
"the  touch,"  in  our  public  lessons,  fur,  in  these  latter,  the  frequently 
repeated  and  careless  introduction  of  a  great  number  of  fingers,  has  appeared 
to  me  to  greatly  accelerate  the  softening  and  dilatation  of  the  neck. 

<  >n  the  whole,  therefore,  the  neck  is  fusiform  in  primiparse,  the  external 
orifice  is  rounded,  and  so  little  dilated  as  to  prevent  the  introduction  of  the 
finger  without  some  considerable  effort.  In  females  who  have  had  children, 
'he  external  orifice  is  widely  open,  ami  the  cavity  in  the  neck  is  funnel- 
shaped,  the  base  being  below,  and  continues  to  increase  until  its  ape: 
reaches  the  internal  orifice.  This  latter  remains  closed  in  both,  in  a  vas: 
majority  of  cases,  until  the  beginning  of  at  least  the  last  month  of  pregnancy 


ORGANIC     CHANGES     DURING     PREGNANCY.  135 

These  differences  in  the  form  of  the  neck  in  primiparae  and  of  multipara, 
are  readily  accounted  for  when  we  take  into  consideration  the  condition  of 
the  external  orifice  before  pregnancy  in  both  cases.  The  os  tincse  of  women 
who  have  already  had  children,  has  the  continuity  of  its  circumference 
interrupted  by  a  greater  or  less  number  of  ruptures,  so  that  as  soon  as  a 
small  part  of  the  neck  has  become  softened,  each  of  the  divisions  of  the 
circumference  being  fixed  only  by  its  upper  part,  is  turned  outward,  so  as 
i  )  give  to  the  orifice  the  form  of  the  large  extremity  of  a  trumpet.  In  the 
primiparous  woman,  on  the  contrary,  the  integrity  of  the  ring  is  complete, 
and  the  os  tineas  may  become  softened  without  its  orifice  being  much 
enlarged  in  consequence. 

We  have  stated  that  the  whole  length  of  the  neck  disappears  at  the  last, 
by  being  confounded  with  the  cavity  of  the  body.  The  mechanism  of  this 
fusion  is  very  simple ;  the  ring  at  the  internal  orifice  having  at  length  lost 
all  power  of  resistance  from  its  ramollissement,  opens  so  as  easily  to  admit 
the  extremity  of  the  finger  (see  Fig.  42),  and  this  dilatation  gradually 
augments  under  the  influence  of  those  feeble  contractions  by  which  the 
uterus,  in  the  last  fortnight  of  gestation,  seems  to  prelude  the  labor  of  child- 
birth, and  as  soon  as  this  is  sufficiently  advanced  to  permit  the  inferior  part 
of  the  ovum  to  engage  in  the  cavity  of  the  neck,  we  can  understand  that  the 
latter  is  promptly  trespassed  upon.  Again,  there  is  no  projection  found  at 
the  upper  part  of  the  vagina,  unless,  perhaps  in  those  who  have  had  children, 
a  collar  of  variable  thickness  and  softness,  circumscribing  an  opening  large 
enough  to  permit  the  finger  to  reach  the  membranes  ;  whilst  in  primiparae, 
only  a  sharp,  thin  ring,  in  the  centre  of  which  is  a  much  more  contracted 
orifice,  will  be  encountered. 

4.  We  have  but  little  to  remark  concerning  the  situation  and  direction 
of  the  uterine  neck  during  pregnancy,  and  our  opinions  do  not  differ  from 
those  held  by  the  majority  of  writers  on  this  subject ;  hence  we  shall  merely 
state,  in  a  few  words,  that  during  the  first  three  months  the  neck  is  lower, 
is  directed  more  in  front,  and  a  little  to  the  left ;  and  that  this  position  is 
the  necessary  consequence  of  the  inverse  movement  of  the  body  of  the  organ, 
by  which  its  fundus  is  carried  backwards  into  the  sacral  cavity,  and  pushed 
to  the  right  by  the  tumor,  which  the  rectum,  habitually  distended  with  fecal 
matters,  forms  behind  and  at  the  left  part  of  the  excavation. 

In  the  last  six  months,  the  cervix,  necessarily  following  the  ascent  of  the 
body,  mounts  upward,  and,  at  the  same  time,  most  generally  looks  back- 
ward and  to  the  left,  whilst  the  fundus  is  nearly  always  carried  forwards 
and  to  the  right. 

I  cannot  pass  over,  however,  a  disposition  of  the  neck  occasionally  met 
with  at  the  end  of  gestation,  that  sometimes  embarrasses  persons  qo1  familiar 
with  this  kind  of  exploration  :  namely,  in  the  last  month,  the  head  (if  that 
is  the  presenting  part)  frequently  presses  before  it,  in  engaging  in  the 
excavation,  the  anterior  inferior  portion  of  the  uterus,  and  in  case  the 
female  has  a  large  pelvis,  this  descends  even  perhaps  down  to  the  inferior  floor. 
The  neck  will  therefore  necessarily  be  carried  behind  the  tumor  which  then 
tills  the  pelvis,  and  the  plane  of  its  orifice  will  look  towards  the  anteiioi 
face  of  the  sacrum,  and,  of  course,  in  order  to  penetrate  its  cavity,  the  linger 


136  PREGNANCY. 

must  be  bent  like  a  book  and  be  introduced  from  bebind  directlj  forwards 
This  posterior  obliquity  of  the  cervix,  which  differs  essentially  from  that 
produced  by  an  anteversion  of  the  womb,  sometimes  renders  it  very  difficult 
of  access,  even  when  the  labor  is  somewhat  advanced.  The  difficulty  ia 
still  further  increased,  in  some  cases,  by  the  softening  of  the  neck  through- 
out, in  consequence  of  which  it  becomes  flattened  and  applied  to  this  tumor 
forming  a  kind  of  fold  or  doubling  on  its  posterior  part. 

Summary.  —  From  what  has  been  stated,  we  may  now  d?aw  the  following 
conclusions: 

1st.  That  the  tissue  of  the  neck  begins  to  soften  at  the  very  commence- 
ment of  pregnancy,  and  the  softening,  although  not  very  apparent  in  the 
earlier  months,  and  limited  to  the  most  inferior  part,  gradually  ascends,  so 
as  to  invade  successively  the  whole  neck  from  below  upwards,  though  it  is 
sometimes  less  marked  and  less  rapid  in  its  progress  in  primiparse  than  in 
other  females. 

2d.  The  cavity  of  the  neck  dilates  simultaneously  with  the  softening  of 
its  walls ;  and  further,  this  enlargement  causes  it  to  be  spindle-shaped  in 
primiparse ;  and,  in  females  who  have  already  borne  children,  to  resemble 
a  thimble,  the  finger  of  a  glove,  or  a  funnel  with  its  base  below. 

3d.  The  external  orifice  remains  either  closed,  or  else  very  slightly  open, 
in  primiparse,  up  to  the  very  term  of  pregnancy,  whilst  in  others  it  is  widely 
open,  and  constitutes  the  base  of  the  funnel 

4th.  The  whole  length  of  the  neck  disappears  in  the  last  fortnight,  being 
lost  in  the  cavity  of  the  body.  The  effacement  beginning  by  the  interna] 
oritice  and  gradually  involving  the  neck  from  above  downward  as  far  as  to 
the  external  orifice. 

5th.  Contrary  to  the  opinions  generally  adopted  before  the  time  of  M. 
Stoltz's  publication,  the  neck  preserves  its  whole  length  until  the  last  fort- 
night ;  it  does  not  shorten  from  above  downward  during  the  last  four  months, 
but  the  fusion  of  the  neck  with  the  body  takes  place  only  within  the  last 
few  weeks  of  gestation. 

§  3.  Modifications  in  the  Texture  of  the  Uterus. 

Among  the  many  changes  which  the  womb  undergoes  during  pregnancy, 
the  most  curious  of  all  are  those  exhibited  in  its  texture;  and  we  shall 
Btudy  these  by  successively  examining  the  different  parts  of  its  constituent 
elements. 

1.  Serous  Coat. — The  peritoneum,  forming  the  external  membrane  of  the 
uterus,  spreads  out  in  all  directions.  The  various  folds  formed  by  it  in  the 
neighborhood  of  the  womb,  a  species  of  mesentery,  as  M.  Dubois  calls  them, 
Buch  as  the  broad  ligaments  and  the  anterior  and  posterior  ligaments,  are 
double.  Many  anatomists  believe  this  doubling  is  even  sufficient  to 
accommodate  the  enlargement  of  the  organ.  But,  to  refute  this  opinion,  it 
is  only  necessary  to  examine  that  portion  of  it  comprised  between  the  com- 
mencement of  the  two  tubes,  which  cover  the  fundus;  for  this  will  afford  a 
convincing  proof  that  it  cannot  be  furnished  by  the  accession  of  neighboring 
parts  of  the  peritoneum,  because,  as  Desormeaux  remarks,  the  insertion  of 
the  tube  and  ligament  of  the  ovary  upon  each  side  presents  an  obstacle  thai 


ORGANIC     CHANGES     DURING     PREGNANCY.  137 

will  prevent  the  gliding  of  the  adjacent  membrane.  The  peritontal  tissue, 
however,  undergoes  a  considerable  extension,  and  a  more  active  nutrition 
must  necessarily  take  place  to  prevent  its  attenuation,  since  that  which 
covers  the  uterus  during  gestation  quite  equals  in  its  thickness  the  serous 
membrane  of  the  unimpregnated  state.  This  extension  of  the  peritoneum, 
without  a  decrease  in  thickness,  is  not  a  new  fact  in  pathology,  and  it  may 
be  seen  in  every  hernia  of  considerable  size. 

The  tissue  uniting  this  membrane  to  the  muscular  substance  appears  to 
have  diminished  in  density  ;  for  the  peritoneal  coat  is  movable  on  the 
muscular  walls,  according  to  M.  Dubois,  who  has  met  with  difficulty  from 
this  cause  every  time  he  has  performed  the  Csesarean  operation. 

2.  Mucous  Coat.  —  Although  the  existence  of  this  coat  in  the  non-gravid 
state  has  been  denied  by  many  anatomists,  it  becomes  very  apparent  during 
pregnancy.  It  then  grows  redder  and  more  vascular,  and  its  folds  dis- 
appear ;  but  this  unfolding  will  not  alone  account  for  the  extension  which 
it  undergoes,  and  it  must,  whatever  be  said  to  the  contrary,  receive,  like 
the  peritoneum,  a  more  active  nutrition. 

All  the  elements  which  we  have  mentioned  (page  80)  as  entering  into  its 
composition  undergo,  in  reality,  a  considerable  development.  The  nature 
of  this  work  does  not  allow  us  to  enter  into  all  the  details  which  the  subject 
demands,  and  we  prefer  referring  the  reader  to  the  excellent  work  published 
by  M.  Robin,  in  the  Archives,  for  the  year  1848,  Vol.  XXV.  of  the  Memoires  de 
VAcadimie  de  Medecine,  and  in  the  Bulletin  de  I'Academie  de  Medecine,  1861. 

The  glands  of  the  body  of  the  womb  share  in  the  general  hypertrophy, 
and  we  shall  be  obliged  to  recur  to  this  subject  when  we  come  to  treat  of 
the  decidua,  which  is  nothing  else,  as  must  be  finally  acknowledged,  than 
the  mucous  membrane  of  the  uterus  modified  by  the  progress  of  gestation. 
(See  Decidua.)  m 

It  is  easy  to  convince  ourselves,  after  the  accouchement,  that  the  mucous 
membrane  of  the  neck  itself  is  also  hypertrophied,  though  much  less  so  than 
that  of  the  body.  Its  glands,  also,  have  undergone  an  enlargement,  their 
secretion  is  much  increased,  and  to  it  is  due  the  gelatinous  plug,  that  is 
to  say,  the  elastic,  dense,  semi-transparent,  and  almost  insoluble  mass  of 
mucus,  which  closes  and  fills  the  cavity  of  the  neck  during  pregnancy. 
That  such  is  the  case  may  be  demonstrated  by  examination  of  the  bodies 
of  women  who  die  during  pregnancy,  when,  if  the  mass  be  detached,  pro- 
longations will  be  found  passing  from  it,  and  entering  the  orifice  of  the 
glands.     (Robin.) 

3.  Middle  Coat. —  [The  middle  coat  of  the  uterus  is  formed  of  muscular  fibres  of 
organic  life,  as  stated  whilst  describing  the  normal  anatomy  of  the  organ.  In  the 
unimpregnated  condition  these  filires  are  hardly  recognizable,  but.  during  pregnancy 
they  become  very  evident.  Numerous  microscopic  researches  have  shed  still  more 
light  on  the  subject,  revealing  the  most  intimate  changes  which  the  muscular  tissue 
undergoes.  According  to  M.  Ch.  Robin,  whose  opinion  is  stated  by  M.  Pajot,  the 
muscular  or  cell  fibres  of  the  uterus  are,  in  the  empty  uterus,  remarkable  for  their 
small  size  and  grayish  color,  making  it  difficult  to  distinguish  them  by  the  raked 
eve  from  the  cellular  texture  which  surrounds  them.  During  pregnancy  tlie\ 
enlarge  in  everv  way,  particularly  in  length,  and  new  fibres  are  formed  beside  the 
old  ones,  especially  in  the  innermost,  layers  of  the  middle  coat 


l: 


PREGNANCY. 


"We  quote  the  text  in  which  Kulliker  treats  of  the  subject,  viz.:  "  The  muscular 
coat  undergoes  an  increase  in  bulk,  to  which  the  enlargement  of  the  uterus  is 
principally  due,  an  increase  resulting  from  the  concurrence  of  two  phenomena: 
the  increase  in  size  of  the  pre-existing  muscular  elements,  and  the  formation  of  :ieic 
ones.  The  first  of  these  is  so  marked  that  the  contractile  fibre  cells,  instead  of  being 
from  05  to  .07  of  a  millimetre1  in  length,  and  .005  in  breadth,  which  is  their  usuil 
>!ze,  measure  in  the  fifth  month  .14  to  .27  m.  m.  in  length,  and  .0055  to  .014  and 
even  .02  in.  m.  in  width  ;  in  the  second  half  of  the  sixth  month  .2  to  .52  m.  m.  in 
length,  .009  to  .014  m.  m.  in  width,  and  .005  to  .000  m.  in.  iu  thickness;  so  that 
they  are  about  from  seven  to  eleven  times  longer,  and  from  two  to  seven  tinier 
\\  idcr  than  at  first. 

"  'J  he  formation  of  new  muscular  fibres  is  especially  noticed  during  the  first  half 
i>f  pregnancy,  and  in  the  internal  layer  of  the  muscular  coat.  Iu  this  situation  are 
found  a  multitude  of  young  cells  of  from  .02  to  .04  m.  m.  in  diameter,  presenting 
all  the  transition  forms  of  cell  fibres  of  from  .05  to  .07  m  m.  in  length;  nothing 
similar  to  this  being  observable  in  the  external  layers. 

"  This  generation  of  muscular  fibres  appears  to  cease  at  the  sixth  month  ;  at  least 
I  have  been  able  to  discover  in  the  uterus  during  the  twenty-sixth  week  of  preg- 
nancy only  enormous  fibre  cells  with  no  traces  of  preceding  forms. 

"  To  this  increase  of  muscular  fibres  corresponds  that  of  the  connective  tissue 
which  unites  them;  toward  the  end  of  pregnancy  the  latter  exhibits  in  some 
places  a  distinct  fibrillation."   (Human  Histology.) 

In  short,  the  increase  in  size  of  already  existing  muscular  elements,  and  the  forma* 
♦ion  of  new  fibres,  concur  in  the  production  of  the  uterine  hypertrophy. 

AVe  have  next  to  exhibit  the  arrangement  and  direction  of  the  muscular  fibres, 
and  in  so  doing  shall  state  successively  the  result  of  the  dissections  of  Madame 
Boivin  and  of  MM.  Deville  and  Helie.l 


Fig.  43. 


A.  According  to  Madame  Boivin,  there  are  two  planes  of  fibres  in  the 
body  of  the  uterus  —  the  one  exterior,  the  other  interior;  the  external 
plane  is  composed  of  fibres  which  run  from  the  middle  line  outwards  and 
downwards  to  the  inferior  third  of  the  organ,  where  they  terminate   upon 

and  aid  in  forming  the  round  ligaments 
situated  there,  while  the  most  superior  ones 
are  distributed  to  the  Fallopian  tubes  and 
the  ligaments  of  the  ovary.  An  exact  idea 
of  the  radiated  disposition  of  the  external 
fibrous  planes,  at  the  superior  and  lateral 
parts  of  this  organ,  may  be  formed  by  im- 
agining the  long  hair  of  the  human  head  to 
be  parted  along  the  whole  middle  line  of  the 
cranium,  and  then  combed  smooth  on  each 
side  in  front,  and  tied  very  tight  opposite 
each  ear. 

Another  muscular  plane  is  found  internally, 
having  an  entirely  different  arrangement; 
these  fibres  are  circular  and  situated  at  the 
superior  angles  of  the  womb.  They  surround 
the  internal  orifice  of  the  tubes  (a  a,  Fig.  43), 
describing    concentric    circles,   at   first   very 


Muscular  Bbree  of  the  uterus,    a  a. 
The  internal  orifices  of  the  Fallopian 


1   A  millimetre  is  .0.039  of  an  inch. 


ORGANIC     CHANGES     DURING     PREGNANCY.  139 

small  and  dose,  but  gradually  separating  as  the  distance  from  the  angles 
increases,  so  that  the  last  and  largest  border  upon  the, median  line,  and 
spread  out  in  the  direction  of  its  length. 

Between  these  two  planes,  the  external  one  composed  of  longitudinal,  and 
the  infernal  one  of  horizontal  fibres,  some  other  muscular  fibres  are  found, 
the  course  of  which  it  is  impossible  to  trace. 

Only  a  single  order  of  fibres,  which  are  semicircular,  exists  at  the  inferior 
part.  They  commence  at  the  median  line  of  this  region,  and  reunite  on  the 
sides  near  the  round  ligaments. 

I  will  remark,  in  terminating  this  short  account  of  the  uterine  structure, 
its  great  resemblance  to  that  of  all  the  hollow  organs,  in  having,  for  instance, 
its  longitudinal  fibres  on  the  exterior,  whilst  the  circular  and  horizontal 
ones  are  internal.  The  fundus  uteri  is  the  part  particularly  concerned  in 
the  expulsion  of  the  foetus,  and  it  is  there  also  that  the  muscular  appa- 
ratus is  the  most  developed ;  its  disposition  is  such,  that  all  parts  of  the 
uterine  surface  tend  towards  the  centre  during  contraction.  Lastly,  at  the 
inferior  part,  where  the  resistance  should  be  least,  there  are  only  the  hori- 
zontal fibres,  constituting  a  sort  of  sphincter  muscle,  which  may  be  com- 
pared, on  more  than  one  account,  to  the  sphincter  of  the  rectum  or  of  the 
bladder. 

B.  Quite  recently,  M.  Deville,  prosector  to  the  hospitals,  has  studied  the 
muscular  arrangement  of  the  uterus  in  a  great  number  of  cases  of  females 
who  died  a  few  days  after  labor,  and  the  results  at  which  he  has  arrived 
differ  much  from  those  previously  acknowledged.  This  subject,  in  my 
estimation,  requires  further  examination  ;  but  whilst  awaiting  an  oppor- 
tunity of  dissecting  for  myself,  the  preparations  of  M.  Deville  appear  so 
satisfactory,  that  1  have  obtained  a  drawing  of  them,  and  introduce  here 
the  description  furnished  by  that  skilful  anatomist. 

Examined  on  its  external  surface,  after  the  removal  of  the  peritoneum 
and  the  compact  resisting  layer  that  separates  this  serous  coat  from  the 
muscular  fibres,  the  uterus  seems  to  be  composed  of  two  orders  of  fibres,  which 
are  essentially  muscular,  one  being  transverse  and  the  other  longitudinal. 

The  transverse  fibres  arise  (this  word  to  be  received  in  a  purely  descrip- 
tive sense)  from  three  sources  :  the  round  ligament,  Fallopian  tube,  and  the 
ligament  of  the  ovary;  also  from  the  wings  of  the  corresponding  broad 
ligament.  The  mere  removal  of  the  delicate  peritoneal  envelope  of  these 
organs  suffices  to  bring  the  transverse  fibres  into  view,  and  at  the  same  time 
to  reveal  their  muscular  character. 

The  transverse  fibres,  together  with  certain  vessels  and  nerves,  constitute 
the  intimate  structure  of  the  round  and  ovarian  Ligaments,  as  also  the 
middle  layer  of  the  Fallopian  tube,  which  is  therefore  essentially  muscular, 
like  the  internal  membrane,  improperly  called  dartoid,  of  all  the  excretory 
canals. 

The  presence  of  a  great  number  of  transverse  uterine  fibres  King  in  the 
thickness  of  the  folds  of  the.  broad  ligament,  and  extending  to  its  base,  i.^ 
an  important  fact  to  be  borne  in  mind  ;  and  the  question  arises,  where  do 
they  terminate?  I  confess  that  I  have  not  been  able  to  determine  this  in  a 
satisfactory  manner. 


140 


PREGNANCY. 


Howevei  the  truth  may  he,  the  transverse  fibres  coming  from  these  divers 
origins  spread  out  in  a  radiated  manner  over  the  whole  exterior  surface  of 
the  uterus,  the  anterior  and  posterior  ones  transversely,  or  a  little  down- 
wards in  an  oblique  direction,  and  the  superior,  obliquely  upwards,  so  as  to 
cover  the  organ  completely.  Near  the  median  line  these  fibres  are  crossed 
perpendicularly  to  their  course  by  a  longitudinal  fasciculus,  more  or  less 
sinuous  in  character,  and  three-eighths  to  three-fourths  of  an  inch  wide,  which 
arises  near  the  point  of  union  of  the  body  with  the  neck,  ascends  upon  the 
fundus  of  the  organ,  and  descends  on  the  posterior  face,  to  be  lost  at  its 
inferior  part  opposite  to  or  a  little  below  the  point  of  beginning,  that  is, 
near  the  union  of  the  body  with  the  neck.  A  positive  continuity  will  be 
observed  between  the  transverse  fibres  of  each  side  and  the  middle  longitu- 
dinal fasciculus,  if  the  line  of  contact  be  carefully  examined. 

As  the  transverse  fibres  arrive  near  the  median  line,  some  curve  down- 
wards, others  upwards,  so  as  to  become  longitudinal,  and  thus  constitute 
the  median  layer.  This  is  particularly  evident  at  its  termination,  both  in 
front  and  behind,  for  the  whole  fasciculus  divides  there  into  two  portions, 
one  of  which  curves  to  the  right,  the  other  to  the  left,  and  becomes  con- 
tinuous with  the  most  inferior  transverse  fibres  of  the  body. 

This  continual  exchange  of  the  two  series  of  uterine  fibres  takes  place 
with  such  great  uniformity,  that  the  longitudinal  fasciculus  has  nearly  the 
Bame  thickness  everywhere;  but  if  this  lamina  be  more  patiently  examined, 

it  will  be  found  to  be  composed  of  very 
FlQ-44-  short  longitudinal  fibres,  forming  the  cen- 

tral part  of  a  letter  X,  which  the  uterine 
fibres  describe,  as  I  have  verified  on  many 
of  my  preparations,  in  the  following 
manner. 

Let  us  take  a  layer  of  transverse  fibres 
on  the  right  side  of  the  uterus,  at  the  an- 
terior inferior  part  (see  Fig.  44);  this 
fasciculus  nearly  approaches  the  median 
line,  then  curves  upward  and  becomes 
confounded  with  the  longitudinal  lamina; 
then,  after  a  vertical  course,  varying 
from  one-third  of  an  inch  to  two  inches, 
it  again  curves  to  the  left,  to  reassume  a 
transverse  direction,  thus  representing  a 
Z,  or  still  more  exactly,  a  branch  of  the 
letter  X. 

Thus,  the  longitudinal  median  layer  is  produced  by  the  union  of  the 
central  and  vertical  branches  of  the  X.  described  by  the  uterine  fibres. 

It  sometimes  happens,  however,  that  the  transverse  fibres  pass  directly 
from  right  to  left  without  forming  the  vertical  branch,  which  fact  should 
be  borne  in  mind  lest  this  arrangement  existing  on  the  surface  might  give 
rise  to  a  belief  of  the  absence  of  a  median  longitudinal  fasciculus;  whereas, 
if  the  latter  is  not  evident,  it  will  only  be  necessary  to  raise  carefully  this 
layer  of  median  transverse  fibres,  to  bring  it  into  view.     The  uterus  exhibits 


The  disposition  of  the  muscular  fibres  on 
the  anterior  face  of  the  womb. 


ORGANIC    CHANGES    DURING    PREGNANCY. 


141 


The  disposition  of  the  muscular  fibres  on 
the  posterior  face  of  the  womb. 


the  same  disposition  of  muscular  fibres  on  the  internal  face,  which  will 
readily  account  for  the  error  of  Madame  Boivin,  Avho  described  them  a? 
circular. 

Notable  differences,  however,  exist  be-  Fro.  45. 

tween  the  fibres  on  the  two  surfaces  of  the 
>rgau.  The  most  remarkable  on  the  ex- 
terior is  the  extreme  breadth  of  the  longi- 
tudinal fasciculus,  which  covers  the  whole 
fundus,  extending  from  the  orifice  of  the 
Fallopian  tube  on  one  side  to  the  same 
point  on  the  other.  When  this  fasciculus 
reaches  the  anterior  and  posterior  faces, 
it  is  intersected  at  right  angles  by  the 
transverse  fibres  occupying  the  lateral 
portions  just  below  the  orifice  of  the 
tubes,  which  act  there  as  on  the  exterior 
surface  :  that  is,  some  of  the  fibres  curve 
upwards,  others  downwards,  becoming  con- 
founded with  the  longitudinal  layer. 
Lower  down,  near  the  junction  of  the  body  with  the  neck,  the  longitudinal 
fasciculus  is  very  irregular.  Sometimes  it  exists;  sometimes,  though  more 
rarely,  it  does  not. 

At  this  point,  in  fact,  the  continuation,  or  inter-crossing  of  the  transverso 
fibres  from  one  side  to  the  other,  occurs  in  an  irregular 
manner,  either  forming  the  vertical  branches  of  an  X,  fio.46. 

or  taking  an  oblique  direction,  or  again  going  directly 
across,  the  fibres  preserving  a  transverse  course. 

A  third  layer  exists  between  the  two  just  described, 
but  I  am  not  sufficiently  acquainted  with  the  disposi- 
tion of  its  fibres  to  give  an  exact  account  of  them. 

All  these  particular  details  do  not  interfere  with  the 
general  law  of  inter-crossing,  or  passage  of  uterine 
fibres  from  one  side  to  the  other,  and  in  this  respect, 
the  uterus  may  justly  be  ranged  in  the  same  class  with 
all  the  other  hollow  muscular  organs  whose  structure  is 
also  regulated  by  the  fundamental  law  of  muscular 
inter-crossing.  Hence,  it  would  not  be  difficult  to  de- 
monstrate that  the  human  uterus,  as  just  described, 
approaches  in  its  structure  quite  as  well,  perhaps  better, 
to  that  of  the  same  organ  in  other  mammiferse,  than  the  arrangement  pointed 
out  by  Madame  Boivin.    But  such  a  discussion  would  be  out  of  place  here. 

In  conclusion,  I  will  observe,  that  the  same  dispositions  in  the  muscular 
arrangement  are  found  in  the  neck  and  inferior  part  of  the  body.  Inter- 
crossings  occur  there  also,  the  fibres  passing  directly  from  one  side  to  the 
other,  or  becoming  more  or  less  oblique  at  the  moment  of  crossing,  and  .-till 
oftener  forming  the  branches  of  an  x  with  the  median  vertical  parts.  This 
last  disposition  gives  rise  to  the  peculiar  formation,  which  has  improperly 
bven  called  the  arbor  vitas. 


Shows  the  Inter-crossing 
of  the  uterine  fibres. 


1  12  PREGNANCY. 

[c.  Lastly,  M.  Helie,  Professor  in  the  Medical  School  at  Nantes,  lias,  in  a 
remarkable  memoir  written  after  long  and  skilful  dissections,  discussed  anew  the 
Bubject  of  the  muscular  structure  of  the  uterus. 

A.8  M.  Hedie  seems  to  represent  the  true  state  of  the  case,  and  gives  a  better  and 
more  complete  exhibition  of  the  arrangement  of  the  muscular  fibres  than  has 
hitherto  been  done,  we  shall  follow  his  description  whilst  pointing  out  the  principal 
results  at  which  he  lias  arrived. 

The  fibres  of  the  uterus,  like  those  of  the  heart,  are  disposed  in  layers,  which 
cover  and  envelop  each  other  successively.  Fibres  pass  frequently  from  one  layei 
to  the  other:  their  arrangement  is  intricate,  and  their  dissection  very  difficult. 
These  superposed  layers  form  the  muscular  structure  of  the  uterus,  and  we  shali 
describe  successively  the  external,  the  internal,  and  the  middle  layer. 

The  external  layer  is  composed  of  several  alternate  planes  of  longitudinal  and 
transverse  fibres.  The  most  superficial  plane  is  longitudinal,  and  is  formed  of  a 
median  fasciculus  whose  middle  part  is  curved  like  a  loop  upon  the  fundus  of  the 
uterus,  whilst  its  two  extremities  descend,  one  upon  the  posterior  and  the  other 
upon  the  anterior  surface  of  the  organ.  This  loop-like  fasciculus  (Figs.  44  and  45) 
always  descends  further  behind  than  in  front.  Behind,  it  begins  where  the  neck 
joins  the  body,  and  is  composed  of  fibres  which,  from  being  at  first  transverse,  by 
a  sudden  change  of  direction  become  vertical,  as  shown  by  M.  Deville.  As  it  ascends, 
the  fasciculus  is  reinforced  by  other  fibres  bent  in  like  manner.  As  it  approaches 
the  fundus,  the  lateral  fibres  curve  outward  toward  the  Fallopian  tubes  and  broad 
ligaments  upon  which  they  disappear. 

The  middle  fibres  of  the  fasciculus  are,  therefore,  the  only  ones  which  bend  over 
the  fundus  of  the  organ,  and  descending  upon  the  anterior  surface  curve  successively 
outward  to  reach  the  broad  and  round  ligaments. 

A  portion  of  the  fibres  which  thus  emerge  from  the  loop-like  fasciculus,  reach 
the  lateral  parts  of  the  organ  only  after  having  traversed  its  median  line  and  passed 
from  one  side  to  the  other.  From  the  right  side,  they  proceed  to  the  left  angle  or 
to  the  left  side  of  the  anterior  surface ;  those,  which  at  their  origin  belong  to  the 
left  side,  go  to  the  right  angle,  or  to  the  right  side  of  the  anterior  surface  of  the 
organ. 

These  crossed  fibres  follow,  therefore,  precisely  the  Z-like  direction  described  by 
M.  Deville.  M.  Helie,  however,  regards  the  crossings  as  far  from  constant,  besides 
being  limited  to  very  few  fibres  ;  the  greater  number  of  the  looped  ones  beginning 
and  ending  upon  the  same  side  without  crossing  the  median  line. 

The  loop-like  fasciculus  is  almost  never  limited  to  one  plane  only.  It  is  always 
thick  upon  the  posterior  surface  of  the  uterus,  sometimes,  though  rarely,  forming  a 
single  plane.  At  other  times,  and  most  commonly,  its  fibres  are  divided  into  two 
planes  separated  by  a  layer  of  transverse  fibres,  the  superficial  layer  being  then 
thin,  and  the  deeper  one  much  thicker. 

Let  us  study  next  those  transverse  fibres  which,  witli  the  preceding  fasciculus, 
form  the  surface  of  the  body  of  the  uterus.  They  constitute  the  greater  pari  of  the 
external  muscular  layer,  and  contribute  to  the  formation  of  the  loop-like  fasciculus 
as  already  stated;  the  greater  part,  however,  being  foreign  to  its  formation  remain 
upon  the  median  line,  passing  below  it  and  between  its  two  layers,  sometimes  even 
upon  its  superficial  posterior  layer.  They  go  from  one  side  to  the  other,  extend 
outwardly  into  the  broad  ligaments,  and  especially  into  the  ligament  of  the  ovary, 
the  round  ligaments,  and  upon  the  Fallopian  tubes. 

If  we  follow  them  in  the  opposite  direction,  they  may  be  said  to  proceed  from  all 

these  points,  and  after  reaching  the  sides  of  the  uterus  to  divide  into  two  layers, 

one  of  which  passes  upon  the  anterior,  and  the  other  upon  the  posterior  surface  of 

gan,  the  uppermost  covering  the  fundus  and  making  arch-like  curves  upoD 

f,he  anjrles. 


ORGANIC   CHANGES    DURING   PREGNANCY. 


1  13 


Via.  47. 


O 


T 


Some  of  the  fibres  leave  the  external  layer  ami  pass  into  the  middle  cne. 

It  should  be  observed  that  the  anatomists  who  have  studied  the  muscular  structure 
?f  the  uterus  have  failed  to  treat  of  the  sides  of  the  organ,  mentioning  only  those 
fibres  which  extend  to  its  annexes;  an  omission  which  M.  Helie  has  supplied. 

If  the  two  layers  of  the  broad 
ligament  with  the  muscular  fibres 
distributed  to  it  be  separated,  trans- 
verse muscular  fibres  going  from 
one  surface  to  the  .other,  are  per- 
ceived throughout  the  entire  ver- 
tical extent  of  the  sides  of  the 
uterus  At  the  sides  of  the  uterus, 
these  fibres  are  so  curved  as  to 
reach  the  surface  opposite  to  the 
one  from  which  they  took  their 
departure.  Such  at  least  is  their  T 
general  arrangement,  though  their 
course  is  a  very  complex  one.  They 
separate  to  afford  passage  to  the 
vessels,  and  do  not  keep  to  their 
primitive  plane  throughout  their 
course.  Thus  in  front  they  are 
superficial,  but  are  more  deeply 
situated  behind,  and  vice  versa. 

Above,  and  on  a  level  with  the 
Fallopian  tubes,  the  fibres  of  the 
sides  of  the  organ  are  arranged 
still  differently.  The  transverse 
ones  which  describe  large  curves 
upon  the  fundus  from  one  angle 
to  the  other,  descend  and  curve 
ag^in  -;pon  the  sides  of  the  organ. 
A  portion  of  these  go  to  the  Fallo- 
pian tube,  and  to  the  round  and  ovarian  ligaments,  the  major  portion,  however, 
descend  upon  the  sides  of  the  uterus. 

In  their  descent  they  meet  the  vessels  which  interrupt  their  regularity,  then  they 
{  ass  more  deeply  and  curve  forward  or  backward  to  become  transverse  upon  one 
surface  or  other  of  the  organ. 

In  the  neck,  the  arrangement  of  the  fibres  is  more  simple,  for  no  trace  of  the 
loop-like  fasciculus  is  found.  Almost  all  the  fibres  pass  somewhat  obliquely  down- 
ward from  the  sides  of  the  uterus  toward  the  median  line,  where  they  interlace 
with  similar  fibres  from  the  opposite  side.  They  pass  upon  the  sides  (if  the  neck 
and  curve  round  from  one  surface  to  the  other  in  the  same  way  as  on  the  body,  the 
most  superficial  passing  outward  with  the  vesico-uterine  and  recto-uterine  folds,  as 
also  with  some  fibres  of  the  bladder,  and  still  lower  with  the  muscular  fibres  of  the 
vagina. 

Internal  Layer.  —  When  the  uterus  of  a  woman  deceased  just  after  delivery  is 
Opened,  the  muscular  fibres  of  the  body  are  found  deprived  of  tin'  mucous  membrane 

which  had  covered  them,  and  which    had    been    transformed    into    the   decidua.      As 

the  mucous  membrane  had  not  undergone  this  change  in  the  neck,  it  there  still 
covers  the  muscular  fibres,  and  is  closely  united  to  them. 

When  the  uterus  is  opened  by  incision,  the  middle  of  the  posteriorwall  is  found  to 
present  uniformly  a  slightly  projecting  triangular  fasciculus,  the  base  of  which  extends 

from  one  Fallopian  tube  to  the  other,  whilst  the  apex   reaches  t"  the  interna!  on 
(he  neck. 


Second  plane  of  the  anterior  muscular  layer. 
A.  Superficial  layer  divided  and  folded  over  upon  the  side* 
of  the   uterus.      B.   Deep  layer  of  the   loop-like   fasciculus 

C.  Transverse  fibres   emerging   from    the   loop-like    plexus. 

D.  Fibres  of  the  neck.     0.  Ovary.     It.  Rectum.     T.  Fallopian 
tube.    V.  Bladder. 


144 


PREGNANCY. 


B 


This  triangular  fasciculus  is  funned  as  the  loop-like  one:  of  horizontal  fibree 
which  curve  suddenly  upward,  and  what  is  singular,  the  new  fibres  which  reinforce 
it  are  always  added  to  its  left  side,  whilst  from  its  right  side  fibres  successively 
emerge  which  become  transverse  by  passing  to  the  right  side  of  the  womb.  These 
fibres  have  precisely  the  form  of  the  letter  Z. 

In  approaching  the  Fallopian  tubes, 
the  triangular  fasciculus  divides  into 
two  small  thin  ones,  of  which  one  on 
each  side  has  its  acute  point  inserted 
into  the  corresponding  Fallopian  tube, 
where  it  suddenly  comes  to  an  end. 
Finally,  transverse  fibres  extended  di- 
rectly from  the  orifice  of  one  tube  to  the 
other,  complete  the  triangular  fasciculus 
by  forming  its  base.     (D.  Fig.  48.) 

A  precisely  similar  triangular  fasci- 
culus exists  upon  the  anterior  wall,  with 
the  single  difference  that  the  transverse 
fibres  whilst  curving  to  a  vertical  direc- 
tion enter  its  right  side,  whilst  from  its 
left  side  fibres  emerge  which  assume  a 
horizontal  direction  in  order  to  reach 
the  left  side  of  the  womb. 

Upon  the  sides  of  these  triangular 
fasciculi,  throughout  the  whole  vertical 
extent  of  the  body  of  the  uterus,  the 
muscular  fibres  of  the  internal  layer 
have  a  transverse  direction,  and  pass 
from  one  surface  to  the  other.  As  they 
approach  the  middle  of  the  anterior  and 
posterior  walls,  some  undergo  an  in- 
flexion to  form  the  triangular  fasciculus, 
whilst  others  in  much  greater  number  pass  beneath  it,  and  continue  their  trans- 
verse direction.  At  the  internal  orifice  of  the  neck  the  transverse  fibres  form  a 
projecting  fasciculus,  which  defines  sharply  the  cavity  of  the  body  and  that  of  the 
u°:k. 

At  the  fundus  of  the  uterus,  that  is  to  say,  above  the  orifices  of  the  Fallopian 
tubes,  the  muscular  fibres  form  arches  directed  from  before  backward,  which  con- 
stitute the  vault  of  the  cavity.  Descending  thus  upon  the  anterior  and  posterior 
su! faces,  they  pass  beneath  the  transverse  band  of  the  triangular  fasciculus  which 
covers  them,  and  finally  curve  and  become  blended  with  the  horizontal  fibres. 

At  the  orifices  of  the  Fallopian  tubes,  the  fibres  of  the  internal  layer  are  dis- 
posed  in  concentric  rings;  the  smaller  being  in  contact  with  the  orifice,  whilst  the 
larger,  often  imperfect,  are  continuous  with  the  arches  of  the  vault,  touching  back 
to  back  those  of  the  opposite  side  as  described  by  Madame  Boivin. 

At  the  neck,  it  is  necessary  to  remove  the  mucous  membrane  in  order  to  see  dis- 
tinctly the  muscular  fibres.  It  is  then  evident  that  the  projection  of  the  arbor 
vitce  is  formed  by  muscular  fasciculi  whose  fibres  separate  on  each  side  to  form 
superposed  arches.  Near  the  external  orifice  the  fibres  of  the  neck  are  almost 
all  annular  and  interlaced. 

Middle  layer.—-  When  the  progress  of  the  dissection  has  removed  successively 
the  loop-like' fasciculus  and  the  different  planes  of  transverse  fibres  which  compose 
the  external  layer,  the  middle  layer,  presenting  an  entirely  different  arrangement, 
is  reached. 


Internal  muscular  layer.    (Anterior  wall.) 
A.   Section  of  the   uterine  walls.     B.  Triangular 
Fasciculi.    C.  Fibres  passing  to  the  Fallopian  tubes. 
D.  Openings  of  the  Fallopian  tubes.     E.  Transverse 
libres.     V.  Vagina. 


ORGANIC   CHANGES    DURING    PREGNANCY.  145 

Between  these  two  layers,  however,  there  is  no  precise  line  of  demarcation,  the 
Jeep  fibres  of  the  external  layer  assuming  gradually  the  arrangement  peculiar  to 
the  middle  layer.  Therefore,  only  after  the  removal  of  tliese  intermediate  laminae, 
can  the  middle  layer  with  all  its  peculiarities  be  clearly  distinguished.  The  same 
observation  applies  to  its  exhibition  by  the  entire  removal  of  the  deep  layer. 

The  middle  layer,  first  indicated  by  the  great  number  of  vessels  which  it  con- 
tains, is  always  thicker  in  the  part  corresponding  to  the  insertion  of  the  placenta. 
It  is  composed  of  bands  of  variable  width,  crossing  each  other  in  all  directions, 
some  being  transverse,  others  oblique,  and  some  again  longitudinal.  Large  orifices 
traversed  by  the  veins  or  sinuses  separate  these  bands  from  each  other  or  even 
the  fibres  of  the  same  band.  The  muscular  fasciculi  are  curved  in  loops  around 
the  uterine  veins,  each  loop  being  crossed  by  another  forming  with  it  a  complete 
ring  which  surrounds  the  vein  ;  a  succession  of  rings  forming  a  canal  for  the  vein. 
Large  rings  produced  in  the  same  way  inclose  several  veins,  each  of  which  has  its 
special  rings  within  the  principal  one.  Most  frequently,  the  loop-like  fasciculus 
forms  but  the  half  or  two-thirds  of  a  circle,  another  fasciculus  completing  it  by 
crossing  its  extremities,  at  the  same  time  becoming  closely  attached  to  them. 

Each  vein  is  therefore  surrounded  by  annular  contractile  fibres,  and  traverses  a 
true  contractile  canal  in  its  course  through  the  middle  layer.  The  arteries,  like 
the  veins,  are  surrounded  by  muscular  rings,  with  this  difference,  however,  that 
the  arteries  are  free  within  the  rings,  whilst  the  veins,  reduced  to  their  internal 
membrane,  adhere  to  the  muscular  fibres. 

According  to  M.  Helie,  the  middle  layer  is  found  only  in  the  body  of  the  uterus 
and  is  absent  in  the  neck.  The  latter,  therefore,  is  formed  simply  by  the  super- 
position of  the  external  and  internal  layers.] 

4.  Vascular  Apparatus. — Towards  the  end  of  pregnancy,  the  uterus  ex- 
hibits an  astonishing  development  of  its  vascular  system.  My  friend,  Dr. 
Jacquemier,  has  for  fifteen  years  paid  much  attention  to  this  subject ;  the 
results  of  his  labor  as  found  in  his  work  are  important,  and  from  them  I 
draw  largely.  "In  studying  the  development  of  the  vascular  system  in 
its  whole  extent,  we  shall  find,"  he  says,  "that  the  augmentation  in  the 
size  of  the  arteries  only  becomes  considerable  as  they  approach  the  uterus. 
Whilst  advancing  between  the  peritoneum  and  the  external  face  of  the 
organ,  and  before  giving  off  their  first  divisions,  they  dilate  and  swell  up, 
and  then  they  furnish  branches  to  the  anterior  and  lateral  parts,  which 
ramify  ad  infinitum;  they  are  not  situated  immediately  below  the  peri- 
toneum, but  are  separated  from  it  by  a  delicate  layer  of  muscular  tissue. 
All  these  ramifications  anastomose  freely  and  penetrate  through  to  the 
internal  surface,  where  they  generally  terminate ;  but  a  large  number  of 
those,  corresponding  to  the  placental  insertion,  traverse  the  mucous  mem- 
brane and  enter  the  placenta.  The  ramifications  of  the  arteries  are  con 
tinuous  with  the  capillaries,  which  in  their  turn  give  origin  to  the  veins. 
That  the  capillary  vessels  become  enlarged  during  pregnancy  has  been 
proved  by  Virchow ;  and  Jacquemier  found  that  they  wore  more  readily 
injected  than  capillaries  are  under  ordinary  circumstances.  This  fact  ex- 
plains the  activity  of  the  uterine  circulation,  as  also  the  rapid  and  profuse 
discharge  of  blood  from  the  arteries  into  the  sinuses. 

If  the  venous  trunks  be  examined,  from  the  point  of  quitting  the  uterus 
to  their  terminations  in  the  hypogastric  vein  and  in  the  vena  cava  interior. 
a   groat  increase   in   capacity   will    be   noticed    for   the  ovarian    veins   are 
10 


146  PREGNANCY. 

almost  as  large  as  the  external  iliaes,  and  the  uterine  are  hut  little  less, 
In  the  substance  of  the  womb,  the  venous  system  presents  itself  as  a  series 
of  canals,  situated  in  the  centre  of  the  muscular  tissue,  at  nearly  an  equal 
distance  from  the  internal  and  the  external  faces:  at  this  point,  the  uterus  is 
traversed  by  a  great  number  of  canals  coming  from  all  directions,  which 
anastomose,  and  form  large  sinuses  at  their  junction  ;  the  whole  constituting 
a  giand  plexus,  several  divisions  of  which  are  large  enough  to  receive  the 
extremity  of  the  little  finger 

These  canals  are  much  larger  opposite  the  insertion  of  the  placenta  than 
elsewhere,  and  they  diminish  in  size  as  they  recede  from  it.  There  is  a 
certain  portion  of  the  uterine  walls,  determined  by  the  placental  insertion, 
where  the  venous  canals  of  the  uterus  traverse  the  mucous  membrane  in 
order  to  be  distributed  to  the  placenta.  (See  Decidua  and  Placenta.)  There, 
in  the  thickness  of  the  inter-utero  placental  decidua  itself  these  vessels 
form,  through  an  enormous  dilatation  of  all  their  branches,  the  large 
sinuses  which  exist  at  the  aiherent  surface  of  the  placenta.  These  sinuses 
communicate  so  freely  with  each  other  as  to  form,  so  to  speak,  a  pool  of 
blood,  divided  up  by  numerous  partitions.  A  proportionably  small  num- 
ber of  orifices  exist  at  intervals,  through  which  this  reservoir  of  blood 
communicates  with  the  sinuses  of  the  muscular  walls.  When  the  after- 
hirth  is  detached,  the  whole  placental  surface  of  the  uterus  is  found  to  be 
riddled  with  holes,  which  look  as  though  they  had  been  made  with  a  punch. 
These  orifices,  which  are  oblique,  like  the  section  of  a  quill  in  making  a 
pen,  close  of  themselves  through  the  depression  of  one  of  the  membranous 
lips  of  the  opening  against  the  other.     (See  Placenta.) 

When  we  come  to  treat  hereafter  of  the  decidua,  we  shall  find  that  the 
arrangement  of  the  vessels  of  the  mucous  membrane  properly  so  called, 
undergoes  changes  during  the  course  of  gestation  ;  the  vascular  network 
of  the  internal  surface,  which  Is  highly  developed  in  the  early  stages,  show- 
ing signs  of  a  commencing  atrophy  at  the  end  of  the  second  month,  and 
diminishing  to  vessels  of  very  small  calibre  by  the  end  of  the  pregnancy. 

A  very  delicate  yet  distinct  web  of  areolar  tissue  envelops  the  uterine 
arteries.  The  veins,  on  the  contrary,  have  only  their  internal  coat,  which 
adheres  intimately  to  the  muscular  substance,  and  no  valves  are  found  in 
their  interior. 

So  great  an  enlargement  of  the  arteries  and  veins  must  be  due  to  some- 
thing more  than  a  mere  unfolding,  since  they  preserve  their  flexuosities 
which  are  increased  rather  than  diminished.  They  must,  therefore,  undergo 
a  change  analogous  to  that  which  takes  place  in  the  fleshy  tissue  of 
the  organ. 

From  what  has  been  stated,  it  is  evident  that  the  blood  flows  to  the  uterus 
in  very  large  quantities,  and  consequently  its  nutrition  is  augmented,  for 
such  an  amount  of  blood  must  certainly  contribute  to  the  growth  of  its 
walls.  But  the  question  then  arises,  is  the  circulation  much  more  active, 
as  many  authors  have  thought?  In  reply,  it  would  appear  from  the  late 
researches  of  M.  Jacquernier,  that  the  venous  circulation  especially  must 
exhibit  an  unusual  slowness,  but  I  confess  the  reading  of  this  last  part  of 
his  memoir  has  nol  convinced  me  on  that  point.     (See  art.  Hemorrhage.) 


ORGANIC     CHANGES     DURING     PREGNANCY.  147 

The  lymphatic  vessels  also  accmire  a  very  considerable  calibre  and  form 
several  planes  in  the  uterine  substance,  the  superficial  of  which  are  the  most 
developed  ;  they  divide  into  two  groups,  those  of  the  neck,  which  run  to  the 
pelvic  ganglia,  and  those  of  the  body,  going  to  the  lumbar  ganglia.  The 
hypogastric  absorbent  trunks,  according  to  Cruikshank,  who  has  described 
and  figured  them,  are  as  large  as  a  goose-quill,  and  the  vessels  themselves 
so  numerous,  that,  when  injected  with  mercury,  the  uterus  appears  to  be  a 
mass  of  lymphatic  vessels.  A  common  dissection,  made  a  few  days  after 
delivery,  will  afford  convincing  proofs  of  their  volume  and  number. 

5.  The  nerves  of  the  womb  have,  of  latter  time,  been  the  subject  of 
numerous  researches,  among  others,  by  Drs.  Robert  Lee,  Jobert,  Rendu, 
and  Boulard.  Agreeably  to  the  latter  anatomists,  whose  conclusions  closely 
correspond  with  those  of  the  English  accoucheur,  the  nerves  are  derived 
from  three  sources:  1st.  From  the  ovarian  plexus  —  few  in  number,  and 
distributed  to  the  angles  and  fundus  uteri.  2d.  From  the  hypogastric 
plexus  —  these  are  specially  destined  to  the  neck;  and  3d.  Some  filaments 
of  the  great  sympathetic,  which  accompany  the  uterine  arteries,  and  are 
apparently  lost  upon  the  neck  and  lateral  parts  of  the  womb.  Among  the 
filaments  constituting  the  ovarian  plexus,  there  are  a  few  which  seem  to 
follow  the  course  of  the  blood-vessels  passing  near  the  ovary,  and  reaching 
the  border  of  the  uterus  at  its  superior  part.  The  filaments  then  penetrate 
into  its  substance  along  with  the  vessels,  apparently  for  distribution  to  the 
muscular  walls. 

The  hypogastric  plexus  furnishes  some  nervous  filaments  as  the  urethra 
crosses  its  anterior  part ;  these  nerves  are  few  in  number,  and  ascend  along 
the  lateral  portions  of  the  neck  (but  not  following  the  vessels),  giving  off 
branches  here  and  there  which  enter  the  uterine  walls,  but  M.  Rendu  has 
not  been  able  to  trace  them  beyond  the  neck.  These  nerves  differ  essen- 
tially from  the  preceding,  both  in  origin  and  distribution,  for  they  come 
from  a  plexus  whose  branches  are  not  distributed  with  the  vessels,  and  which 
has  frequent  anastomoses  with  the  sacral  nerves  or  nerves  of  animal  life. 

The  whole  body  of  the  uterus,  therefore,  receives  the  nerves  of  organic 
life  exclusively,  whilst  the  nervous  apparatus  of  the  neck  alone  has  com- 
munications with  the  spinal  nerves.  Like  the  lymphatic  and  sanguineous 
vessels,  the  nerves,  according  to  some  authors,  undergo  a  considerable 
development  during  gestation.  In  the  preparations  exhibited  by  Robert 
Lee  to  the  inspection  of  the  Royal  Society,  and  also  in  the  two  figures  given 
by  him,  large  nervous  bands  are  seen  below  the  serous  tunic,  and  these 
bands  are  so  voluminous  that  many  anatomists  have  doubted  their  true 
structure,  and  regarded  them  as  furnished  by  a  gelatinous  or  cellular  mem- 
brane, placed  between  the  peritoneum  and  the  muscular  coat.  Consequently, 
in  accordance  with  this  view,  the  uterine  nerves  do  not  form  an  exception, 
as  was  for  a  long  time  supposed,  to  the  hypertrophy  seen  in  all  other  parts 
of  the  organ  during  pregnancy  —  for  they  likewise  are  developed  in  every 
way,  and  return  after  the  delivery  to  their  normal  size.  (See,  for  further 
details,  the  memoir  of  Dr.  Robert  Lee,  "  On  the  Ganglia  and  the  other 
Nervous  Structures  of  the  Uterus")  It  is  generally  admitted,  however,  thai 
the  neurilema  is  the  part  chiefly  affected  by  the  hypertrophy. 


148  PREGNANCY. 

The  preparations  deposited  by  M.  Boulard  in  the  Museum  of  the  Faculty, 
and  the  works  of  Robert  Lee,  Ludovic  Hirschfeld.  and  Riehet,  have  con- 
vinced us,  that  exceedingly  fine  filaments  are  prolonged  even  to  the  lowest 
parts  of  the  os  tineas,  and,  consequently,  that  no  portion  of  the  organ  is 
entirely  destitute  of  them. 

ARTICLE    II. 

CHANGES  IN  THE  PROPERTIES  OF  THE  UTERUS. 

[Sensibility.  —  The  sensibility  of  the  uterus  undergoes  little  alteration.  It  is 
well  known  that  in  the  unimpregnated  state  the  neck  may  be  touched  almost  with- 
out the  woman  being  aware  of  it,  and  it  may  even  be  cauterized  without  giving 
rise  to  definite  pain.  The  same  observation  is  almost  applicable  to  the  organ  in 
the  pregnant  condition,  so  that  it  were  wrong  to  suppose  that  its  sensitiveness  is 
much  increased  during  gestation.  The  sensibility  varies,  however,  with  the  cause 
which  excites  it;  a  forced  distention,  for  example,  seeming  to  us  to  give  rise  to 
considerable  pain.  To  avoid  exaggeration,  it  may  be  said  that  sensibility  exists  in 
the  neck,  but  is  obscure  during  as  well  as  before  pregnancy.] 

The  body  of  the  uterus  appears  to  be  even  less  sensitive  than  the  neck. 
I  am  aware  that  most  women  feel  the  motions  of  the  child,  but  are  these 
movements  perceived  by  the  walls  of  the  abdomen,  or  by  the  uterine 
parietes?  The  fact  that  in  women  affected  with  ascites,  the  active  motions 
are  much  more  obscure  than  in  other  females,  tempts  us  to  accept  the 
former  hypothesis.  I  have,  besides,  frequently  known  women  to  pass 
through  the  whole  course  of  gestation  without  feeling  the  motions ;  for 
instance,  I  saw  a  patient  at  La  Charite,  in  August,  1839,  who,  although 
advanced  to  seven  months,  doubted  her  pregnancy  because  she  had  not  felt 
the  child  stir.  I  saw  her  frequently  afterward  between  this  time  and  near 
the  last  of  October,  when  her  labor  occurred,  yet,  although  the  child  was 
quite  strong  and  healthy,  she  had  never  observed  its  motions. 

[The  body  of  the  womb  must  not,  however,  be  regarded  as  entirely  insensible, 
for  the  contractions  of  labor  or  the  introduction  of  the  hand  give  rise  to  quite  severe 
pain.  We  shall  recur  to  this  subject  when  studying  the  subject  of  the  pains  of 
labor.     (See  Phenomena  of  Labor.) 

Irritability.  —  Having  treated  of  its  sensibility,  we  have  a  few  words  to  say  of 
the  irritability  or  organic  sensibility  of  the  womb,  meaning  thereby  the  vital 
activity  peculiar  to  the.  nervous  system  of  the  uterus,  and  other  parts  supplied  from 
the  same  source.] 

This  irritability  is  notably  increased  during  gestation:  to  it  is  due  the 
kind  of  sympathetic  relation  which  is  established  between  the  fibres  of  the 
neck  and  those  of  the  body  of  the  uterus,  and  in  consequence  of  which,  any 
rather  active  and  prolonged  excitement  of  the  neck  of  the  organ  reacts  upon 
the  fibres  of  the  fundus. 

Even  the  premature  expulsion  of  the  foetus  is  often  a  consequence  of  con- 
tractions produced  by  excitations  of  the  cervix,  and  it  is  owing  to  this  cause, 
according  to  Delamotte,  that  repeated  coition  has  frequently  caused  abortion. 
and  that  females  who  are  used  in  our  amphitheatres  for  practising  "  the 
touch,"  are  so  often  delivered  before  term. 

This  irritability  of  the  cervix,  and  its  influence  upon  the  contractility  of 


ORGANIC     CHANGES     DURING     PREGNANCY."  14!) 

the  body  is  in  some  cases  turned  to  profit  in  the  practice  of  our  art ;  thus  it 
is  well  known,  that  one  of  the  surest  and  most  generally  employed  methods  of 
inducing  pr< .mature  labor,  consists  in  the  introduction  and  retention  of  a 
foreign  body  in  the  neck  of  the  womb. 

[Contractility. — By  this  is  meant  the  power  with  which  the  fibres  of  the  -womb 
are  endowed  of  closing  upon  the  body  which  it  contains  for  the  purpose  of  expelling 
it  from  its  cavity.  It  is  a  true  contraction,  precisely  similar  to  the  muscular  con- 
traction of  all  hollow  organs,  such  as  the  bladder,  rectum,  or  stomach. 

The  power  of  contraction  exists  even  in  the  unimpregnated  condition,  especially 
at  the  menstrual  periods ;  at  which  time,  in  exceptional  cases,  it  gives  rise  to  the 
severe  pain  experienced  by  those  who  suffer  from  dysmenorrhoea.  During  preg- 
nancy, the  uterine  contractility  becomes  more  evident  though  still  feeble  and  pain- 
less ;  during  labor  only  does  it  acquire  its  full  energy,  and  is  then  productive  of 
intense  suffering.] 

The  pain  which,  during  labor,  accompanies  the  uterine  contraction,  is 
usually  very  great  in  the  human  species,  but  does  not  exist  at  all  in  wild 
animals,  and  is  only  observed  to  a  very  feeble  degree  in  our  domesticated 
ones.  As  a  general  rule,  the  uterine  contraction  is  not  painful  in  the  differ- 
ent species  of  animals,  unless  an  accident  or  some  disease  renders  a  greater 
energy  of  action  necessary  on  the  part  of  the  organ,  and  the  pains  then 
experienced  by  the  female  are  altogether  similar  to  those  of  women. 

If,  therefore,  the  contraction  is  only  painful  accidentally,  as  it  were,  in 
animals  and  merely  in  consequence  of  a  particular  morbid  condition  of  the 
uterine  fibre,  are  we  not  justified  in  referring  the  pain  in  the  human  species 
to  the  same  cause  ?  Now  can  this  predisposition  be  the  result  of  the  refine- 
ments of  civilization  ?  It  would  of  course  be  impossible  to  prove  this,  but 
there  are  strong  grounds,  at  least,  for  believing  that  such  is  the  fact,  when 
we  reflect  that  our  domestic  animals,  which,  like  ourselves,  have  been  trans- 
lated from  their  primitive  normal  condition,  often  surfer  much  more  during 
parturition  than  those  in  a  savage  state. 

This  contractility  resides  in  all  the  muscular  fibres  of  the  womb,  both 
body  and  neck,  though  the  great  development  of  the  muscular  layers  of  the 
body  causes  the  contraction  to  be  most  powerful  in  that  portion.  Its  inten- 
sity is  exceedingly  variable  in  different  females,  being  very  strong  in  some, 
and  scarcely  existing  in  others;  but  its  energy  bears  no  relation  to  thai  of 
the  external  muscular  system,  for  some  strong  muscular  women  have 
extremely  weak  contractions  during  labor,  and  oftentimes  the  contrary  is 
observed. 

The  exercise  of  this  function  takes  place  independently  of  the  will,  at  least 
in  a  great  majority  of  cases,  which  indeed  we  can  readily  understand  must 
be  the  fact,  from  the  origin  and  nature  of  the  nerves  distributed  to  the  body 
of  the  uterus,  since  we  have  just  learned  that  its  fundus  receives  filaments 
from  the  great  sympathetic  alone.  I  am  well  aware  the  books  furnish  some 
cases  of  women  who  had  the  power  of  suspending  the  contraction  at  will; 
but  if  the  facts  have  even  been  well  observed,  they  have  failed  perhaps  to 
receive  the  most  rational  interpretation.  In  the  eases  related  by  Baude- 
Iocque  and  Velpeau,  in  which  the  labor  ceased  when  the  students  were  sum- 
moned to  witness  it  and  began  again  when  these  numerous  observers  retired, 


150  PREGNANCY. 

the  will  had  probably  less  to  do  than  the  imagination  and  modesty,  with  the 
alternations  of  retardation  and  acceleration  ;  for  though  the  influence  of  the 
will  may  be  reasonably  doubted,  it  cannot  be  denied  that  moral  disturbances 
appear  to  affect  the  contractility  of  the  uterus;  thus,  a  violent  emotion  has 
often  sufficed  to  arouse  it  long  before  the  ordinary  term  of  gestation,  and  it 
is  not  at  all  uncommon  for  the  contraction  to  diminish  or  disappear  for 
several  hours,  or  even  days,  under  the  operation  of  such  causes.  Dewees 
knew  the  pains  to  be  suspended  in  this  manner  for  two  weeks  in  a  woman 
who  was  greatly  affected  by  his  sudden  and  unexpected  arrival.  Betschler 
cites  a  case  in  which  the  pains  were  suddenly  suspended  by  a  violent 
tempest,  so  that  the  neck,  though  widely  dilated,  closed  again,  nor  did  the 
labor  recommence  until  nineteen  days  had  elapsed. 

Everv  day,  indeed,  we  witness  a  suspension  of  the  pains  for  half  an  hour, 
and  sometimes  even  for  several  hours,  upon  visiting  women  whose  modesty 
is  shocked  by  our  presence. 

The  exercise  of  this  function  is  seldom  of  long  duration,  lasting  for  a  few 
seconds  only  —  rarely  beyond  one  or  two  minutes,  and  then  the  organ  which 
was  so  strongly  contracted  and  hardened,  gradually  regains  its  primitive 
state,  and  remains  in  repose,  until,  under  the  influence  of  the  same  stimulus, 
it  is  again  thrown  into  action.  The  organic  contractility,  like  all  mus- 
cular power,  is  expended  by  a  prolonged  exercise,  and  hence  we  can  under- 
stand why  the  pains  so  often  become  at  once  more  slow  and  feeble  or  even 
cease  altogether  after  a  prolonged  labor.  Lastljr,  opiates  have  a  marked 
influence  over  them  ;  for  by  employing  these  preparations,  we  may  suspend 
the  uterine  contraction  nearly  at  will,  for  several  hours  during  labor  at  term, 
and  indefinitely,  in  a  case  of  premature  delivery  or  abortion. 

This  contractility  may  be  excited  by  natural,  accidental,  or  artificial 
stimuli :  thus,  all  the  causes  of  labor  constitute  the  first ;  the  second  are 
those  of  abortion  and  premature  labor ;  and  the  third  comprise  all  irrita- 
tion whatever  of  the  neck  or  body  of  the  womb  ;  as  electricity,  ergot,  and, 
in  a  word,  all  the  means  employed  when  it  is  desirable  to  deplete  the  organ. 

On  the  contrary,  it  may  be  weakened  by  an  over-distention  of  the  uterus, 
by  prolonged  contractions,  or  vivid  moral  impressions. 

An  observation  of  M.  Brachet's  might  lead  to  the  supposition  that  the 
contractility  of  the  uterus  would  be  weakened,  or  even  totally  destroyed, 
by  lesions  of  the  spinal  marrow.  Experiments  upon  animals  have,  besides, 
shown  that  complete  destruction  of  the  cerebro-spinal  axis  abolishes  the  senso- 
motor  functions  of  the  great  sympathetic  nerve.  The  uterus  would,  there- 
fore, be  paralyzed  in  an  experiment  of  this  kind.  It  is,  however,  proved  by 
numerous  cases  of  paraplegia  in  females,  as  well  as  by  experiments  on  ani- 
mals, that  labor  is  in  no  respect  impeded  by  alterations  of  the  cord,  that  the 
uterus  continues  to  contract,  and  that  the  want  of  action  of  the  voluntary 
muscles  is  largely  compensated  for  by  the  paralysis  of  those  of  the  perineum, 
the  slighl  resistance  of  which  renders  the  last  stage  of  the  fetal  expulsion 
both  more  easy  and  rapid. 

This  result  might  indeed  have  been  anticipated  from  the  known  absence 
of  all  nerves  of  animal  life  from  the  body  .if  the  uterus. 

The  contractility  of  the  uterus,  like  that  of  all  the  viscera  of  organic  life, 


ORGANIC     CHANGES    DURING     PREGNANCY.  15] 

is  retain^  for  some  time  after  death,  and  thus  serves  to  explain  tne  oeca 
sional  expulsion  of  a  foetus  several  hours  subsequent  to  the  decease  of  a 
mother,  as  also  the  posthumous  contraction  of  the  uterus  in  Csesarean  opera- 
tions performed  immediately  after  the  mother  has  expired. 

[Retractility.  —  The  term  retractility  seems  both  to  myself  and  M.  Pajot  much 
preferable  to  that  of  contractility  of  tissue,  by  which  it  has  often  been  designated. 

Retractility  is  a  property  in  virtue  of  which  the  uterus,  when  relieved  partly  or 
entirely  of  its  contents,  subsides  upon  itself.  It  is  a  sort  of  elasticity,  differing  from 
contractility  in  being  permanent  and  keeping  the  walls  of  the  organ  closely  applied 
to  the  ovum,  whilst  the  latter  is  intermittent  and  temporary.  A  principal  office  of 
chis  retractility  is  that  of  closing  the  open  orifices  of  the  utero-placental  vessel* 
after  labor,  which  without  it  would  give  rise  to  mortal  hemorrhage.] 

The  retractility  exists  chiefly  in  the  fibres  of  the  body.  Dewees  supposed 
it  to  be  seated  more  especially  in  the  circular  ones  that  constitute  the 
internal  plane  of  the  uterine  muscular  layer,  and  it  is  scarcely  observable 
at  the  inferior  parts  and  in  the  neck.  It  was  certainly  a  wise  provision  on 
the  part  of  nature  to  place  it  in  a  region  where  the  habitual  attachment  of 
the  placenta  causes  a  more  considerable  development  of  the  vascular 
apparatus.  This  holds  so  true,  that  it  is  easy  to  detect  the  retracted  fundus 
in  the  hypogastric  region  after  delivery,  as  a  hard,  irregular  tumor,  whilst 
to  the  vaginal  touch,  the  neck  appears  soft,  flexible,  and  not  the  least  con- 
tracted. Therefore,  whenever  the  placenta  is  inserted  on  the  neck,  a  hemor- 
rhage is  not  only  to  be  dreaded  during  labor,  but  also  at  the  time  of,  and  for 
a  short  period  subsequent  to,  the  delivery  of  the  after-birth.  In  most  female-, 
the  retractility  accompanies  the  contractility,  and  these  two  properties  are 
successively  in  action  at  the  period  of  labor,  and  during  the  gradual  deple- 
tion of  the  uterus.  In  fact,  if  after  the  contraction  which  has  caused  the 
expulsion  of  a  certain  part  of  the  body  inclosed  in  the  uterine  cavity,  the 
walls  of  this  organ  did  not  retract  promptly  to  fill  up  the  void,  it  would 
constitute  inertia  of  the  womb. 

The  retractility  acts  slowly  and  continuously,  and  is  prolonged  throughout 
the  period  of  the  getting-up.  When  it  takes  place  in  a  regular  manner,  it 
is  unaccompanied  by  pain,  as  we  see  in. the  cases  of  many  primiparous  women, 
in  whom  the  retraction  is  accomplished  without  their  being  aware  of  it. 

The  retractility  is  not,  however,  always  equal  to  this  effect,  at  least  during 
the  first  days  after  labor.  Its  insufficiency  may  perhaps  be  due  to  over- 
distention,  or  to  a  protracted  or  too  rapid  labor,  in  which  cases  the  uterine 
fibre  loses  its  elastic  property,  as  Leroux  expresses  it,  or  else  it  may  be  that 
the  presence  of  a  foreign  bod)-,  whether  solid  or  fluid,  requires  the  interven- 
tion of  a  more  active  force.  Here,  then,  the  contractility  is  called  into  exer- 
cise, and  the  retraction  of  the  uterus  is  effected  by  a  true  intermit  tent  and 
painful  contraction. 

This  diminution  of  the  retractility  is  generally,  however,  of  short  lu rat  ion, 
for  after  four  or  six  days  at  the  furthest,  the  contractility  is  no  longer 
required,  unless  a  new  clot  should  happen  to  form  in  the  uterus.  The 
elasticity  of  the  uterine  fibres,  assisted  by  the  process  of  absorption,  which 
goes  on  unceasingly,  and  also  by  the  lochia!  discharge,  are  thenceforth 
sufficient  to  restore  the  organ  to  its  normal  condition. 


152  pregnancy. 

The  retractility  is  far  from  being  equally  powerful  in  all  women,  nur  is 
it  always  easy  to  give  a  good  reason  for  the  difference.  For  example,  it  is 
much  less  active  in  multipara?  than  after  a  first  labor,  and  this  explains 
why  after-pains  are  much  more  common  with  the  former  than  in  the  latter 
case,  for  the  pains  are  a  consequence  of  the  exercise  of  the  contractility,  and 
the  uterus  returns  more  slowly  to  its  habitual  volume.  Great  over-distention 
of  the  womb,  and  a  too  rapid  or  too  prolonged  expulsion,  also  seem  to 
diminish  its  action. 

If  it  be  indisputable  that  there  are  circumstances  which  diminish  the 
elasticity  of  the  uterine  fibres,  it  is  also  fully  proved  that  we  possess  certain 
agents  capable  of  exciting  its  action.  Thus,  external  or  internal  irritations 
acting  on  the  neck  and  body  (such  as  cold  or  frictions),  and  the  adminis- 
tration of  ergot,  often  have  this  happy  effect. 

ARTICLE    III. 

CHANGES    IN   THE   NEIGHBORING   PARTS. 

We  can  readily  imagine  that  the  modifications  just  studied  do  not  take 
place  in  the  uterus  without  affecting  the  neighboring  parts,  and  the  changes 
in  these  will  next  engage  our  attention. 

1.  As  the  uterus  gradually  rises  in  the  abdomen,  its  surrounding  peri- 
toneum is  carried  along  with  it ;  the  folds,  called  the  broad  ligaments,  then 
disappear,  and  consequently  the  Fallopian  tubes  and  ovaries  are  drawn 
nearer  to  the  body  of  the  uterus,  where  they  lie  very  nearly  in  a  vertical 
direction;  the  fundus  becomes  rounded,  its  angles  diminish  and  finally 
disappear.  The  Fallopian  tubes,  which  in  the  unimpregnated  state  are 
inserted  at  the  apex  of  the  angles,  and  on  the  same  horizontal  line  with  the 
fundus,  are  no  longer  implanted  upon  the  highest  part,  but  correspond  to 
the  upper  fourth,  or  even  to  the  middle  of  the  total  length  of  the  organ. 
The  round  ligaments  are  then  composed  of  short  linear  fibres,  among  which 
a  great  number  of  muscular  ones,  prolongations  of  those  of  the  uterus,  and 
having  the  same  contractility,  may  be  distinguished.  M.  Velpeau  asserts 
that  he  discovered  and  watched  their  contraction  in  three  different  females, 
during  the  efforts  of  the  uterus  to  expel  the  after-birth.  The  greater  devel- 
opment of  the  anterior  than  of  the  posterior  wall  of  the  uterus,  removes  the 
insertion  of  the  round  ligaments  from  the  lateral  position  which  they  occupy 
in  the  unimpregnated  organ,  to  a  point  so  much  farther  in  front,  that  they 
are  implanted  at  about  the  union  of  the  anterior  fifth  with  the  posterior 
four-fifths  of  the  antero-posterior  diameter. 

2.  As  the  womb  and  upper  part  of  the  vagina  are  intimately  associated, 
the  latter  is  necessarily  shortened  as  the  former  enlarges  in  the  early  periods 
of  pregnancy,  whilst  the  vagina  becomes  longer  when  the  womb  rises  above 
the  superior  strait.  The  venous  system  in  the  vaginal  walls  is  considerably 
developed,  owing  to  the  greater  activity  of  their  circulation.  This  dilata- 
tion of  the  veins  is,  doubtless,  the  consequence  of  a  greater  vitality  in  the 
genital  organs,  but  it  is  also  due  in  part  to  the  stasis  of  the  blood,  which  is 
impeded  in  its  course  by  the  uterine  development. 

The  varicose  stale,  and  the  nodosities  frequently  encountered  by  the 
finger  on  the  vulva  and  vagina  towards  the  end  of  pregnancy  (described 


OUliANIC    CHANGES     DURING     PREGNANCY.  153 

by  M.  Deneux  under  the  name  of  thrombus),  which  certainly  predispose 
females  to  hemorrhagic  accidents,  may  probably  be  attributed  to  the  same 
cause ;  and  this  congestion  even  affects  the  capillaries ,  for  otherwise  it 
would  be  difficult  for  me  to  explain  the  livid  spots  or  discolorations,  resem- 
bling wine-lees,  presented  by  the  vaginal  mucous  membrane,  aud  to  which 
attention  has  again  been  recently  called  as  affording  a  sign  of  pregnancy.1 
But  unfortunately  this  sign  can  only  be  serviceable  in  a  medico-legal  case, 
because  in  private  practice  very  few  females  would  permit  such  explorations. 

In  practising  the  "touch,"  the  finger  frequently  detects  some  arterial 
pulsations  at  the  upper  part  of  the  vagina,  though  they  are  more  frequently 
found  on  some  point  of  the  supra-vaginal  portion  of  the  uterus,  and  are 
evidently  due  to  the  great  hypertrophy  of  the  vaginal  and  uterine  arteries. 
Doctor  Osiander,  of  Gottingem  attaches  great  importance  to  this  as  a  diag- 
nostic sign,  and  has  called  it  the  vaginal  pulse? 

It  is  not  uncommon  to  find  the  mucous  membrane  of  the  vagina  covered, 
about  the  seventh  or  eighth  month,  throughout  its  whole  extent,  with 
myriads  of  little  pimples  as  large  as  a  pin's  head.  These  small  granula- 
tions, which  I  have  frequently  met  with,  always  coincide  with  a  marked 
increase  of  the  vaginal  secretion,  and  have  given  rise  to  the  term  granular 
vaginitis  of  pregnant  women. 

The  vaginal  mucosities  are  always  secreted  abundantly  during  preg- 
nancy, but  the  time  of  their  appearance  is  very  uncertain.  Usually,  how- 
ever, they  are  more  copious  in  the  advanced  stages,  and  the  women  then 
say,  "they  are  losing  the  milk;"  an  opinion  unworthy  of  refutation.  In 
some,  this  flow  appears  in  the  early  months,  then  ceases,  and  again  reappears 
several  times ;  though  perhaps  not  at  all,  or  else  only  at  a  very  late  period. 

3.  The  bladder  is  gradually  pushed  above  the  superior  strait,  the  meatus 
urinarius  is  drawn  out  and  elongated,  and  its  orifice,  from  being  so  high  up, 
is  concealed  behind  the  border  of  the  symphysis  pubis,  thereby  rendering 
the  introduction  of  an  instrument  very  difficult.  The  urethral  canal  is 
more  curved  than  usual,  and  the  curvature  is  sometimes  so  great  that  the 
male  catheter  can  more  readily  be  used  ;  because  the  bladder  being  strongly 
pushed  forwards,  and  above  the  pubis,  by  the  developed  uterus,  draws  this 
canal  upwards,  and  causes  it  to  be  applied  against  the  posterior  face  of  the 
pubic  symphysis,  thus  producing  a  curvature  of  the  urethra  having  its  con- 
cavity in  front.  Lastly,  as  the  upper  part  of  this  canal  is  compressed  by 
the  enlarged  womb,  the  circulation  in  its  inferior  parts  is  impeded,  and  the 
whole  tube  becomes  greatly  tumefied.  It  is  placed  behind  the  osseous  pro- 
jection produced  by  the  posterior  part  of  the  articular  surfaces  of  the  pubis, 
and   these  two  superposed  eminences  form  a  considerable   tumor  in   the 

1  This  discoloration  is  evidently  owing  to  the  greater  activity  of  the  circulation  in 
the  genital  organs,  and  consequently  it  ought  to  be  met  with  in  all  cases  predisposing 
to  a  vascular  congestion  of  the  genito-urinary  apparatus.  Mr.  Montgomery  has  de- 
tected it  in  a  female  at  the  menstrual  period,  and  it  is  a  well -known  fact,  that  cattle- 
breeders  ascertain  whether  an  animal  is  in  heat  or  not,  by  exnmining  the  orifice  and 
internal  surface  of  the  vagina,  which  is  almost  as  black  as  ink  under  such  circumstances 

2  'flic  hypertrophy  of  the  vessels  of  the  vagina  and  of  the  vulva  sometimes  renders 
wounds  of  these  parts  very  dangerous.  Profuse  hemorrhage  lias  been  known  to  occur 
<n  consequence  of  it. 


154  PREGNANCY. 

interior  of  the  pelvis.  I  have  frequently  known  students  who  were  prac- 
tising the  touch,  to  be  unable  to  explain  the  remarkable  tumefaction 
encountered  by  the  finger  behind  the  symphysis. 

An  annoying  vesical  tenesmus  is  often  produced  by  the  pressure  exercised 
on  the  body  and  neck  of  the  bladder,  tormenting  the  female  with  frequent 
ineffectual  desires  to  urinate ;  these  demands  are  always  very  urgent,  and  are 
satisfied  by  the  discharge  of  a  few  drops  of  urine,  but  are  again  reproduced 
with  equal  intensity  some  minutes  after.  Some  persons,  judging  from  thin 
frequent  micturition,  have  thought  the  urinary  secretion  was  augmented. 

In  certain  cases,  the  swelling  of  the  urethral  walls,  and  possibly  also  the 
compression  they  sustain,  produces  its  complete  obliteration  and  renders 
catheterism  necessary. 

M.  Velpeau  avers,  that  he  has  frequently  known  the  bladder,  from  the 
fact  of  its  being  more  compressed  above  the  fundus  than  below  it  during  the 
last  fortnight  of  pregnancy,  to  project  into  the  upper  part  of  the  vagina  so  as 
to  form  a  true  vaginal  cystocele.  I  think,  however,  that  it  is  of  rare  occur- 
rence during  pregnancy,  since  I  have  met  with  but  two  instances  of  it. 

4.  The  pressure  of  the. uterus  upon  the  vascular  trunks,  which  go  to  or 
return  from  the  inferior  extremities,  genital  organs,  and  lower  part  of  the 
rectum,  interrupts  the  venous  and  lymphatic  circulation  in  those  parts ; 
whence  it  frequently  happens  that  a  considerable  oedema  of  the  limbs  and 
sexual  organs  is  produced,  as  well  as  the  development  of  some  hemorrhoidal 
tumors. 

5.  Pregnant  women  are  habitually  costive;  hence  a  voluminous  tumor  is 
formed  at  the  lateral  posterior  part  of  the  excavation  by  the  rectum  dis- 
tended with  fecal  matters.  The  pressure  of  the  uterus  upon  the  entire  mass 
of  the  intestines,  frequently  gives  rise  to  colic  and  disorders  of  digestion. 

6.  The  base  of  the  thorax  is  enlarged  and  projects  in  front ;  the  diaphragm 
is  pressed  upward  by  the  uterus  and  intestinal  mass,  having  its  concavity 
increased  in  consequence;  so  much  so,  indeed,  as  to  obstruct  respiration,  and 
the  circulation  in  the  heart  and  great  vessels. 

7.  The  skin  of  the  abdomen  is  very  much  distended,  and  is  marked,  espe- 
cially towards  its  inferior  part,  by  some  streaks  of  a  brown  or  bluish  color, 
which  form  parallel  curved  lines  with  the  convexity  towards  the  pubis  and 
groins.  These  are  very  numerous  in  some  women,  but  in  others  they  scarcely 
exist ;  they  become  paler,  but  do  not  disappear  altogether  after  the  delivery  ; 
sometimes  they  are  continued  even  to  the  upper  and  internal  part  of  the 
thighs,  and  not  unfrequently  involve  the  skin  of  the  lumbar  and  gluteal 
regions. 

The  muscles  and  aponeuroses  of  the  abdominal  walls  become  thinner,  the 
recti  muscles  are  removed  from  each  other,  and  the  aponeurotic  space  which 
separates  them,  instead  of  being  a  narrow  hand,  as  usual,  is  at  least  four 
and  a  quarter  inches  wide,  on  a  level  with  the  navel.  The  umbilical  depres- 
sion, which  in  the  two  first  months  seems  deeper,  disappears  gradually  as 
gestation  progresses;  the  rim:  becomes  <listended,  and  most  generally  the 
skin  exhibits  a  protuberance  instead  of  a  pit  in  its  place.  The  eminence  is 
particularly  well  marked  when  the  female  exerts  herself,  owing  to  the 
engagement  of  a  small  piece  of  epiploon  in  it,  constituting  a  temporary 
hernia. 


OKGANIC     CHANGES     DURING     PREGNANCY.  155 

Not  unfrequently  an  oblong  tumor  appears  on  the  median  line  aftei  de- 
livery, produced  by  a  projection  of  the  bowels  in  consequence  of  tiie  great 
separation  of  the  aponeurotic  fibres.  The  tumor  is  especially  evident  dur 
ing  any  exertion ;  and  increases  in  size  with  each  succeeding  pregnancy. 
until  it  finally  becomes  an  infirmity,  which  obliges  the  woman  to  have 
recourse  to  a  bandage. 

8.  The  relaxation  of  the  pelvic  symphyses  is  a  frequent  occurrence;  when 
existing  to  a  great  extent,  it  constitutes  a  disease  that  will  be  more  fully 
detailed  in  the  pathological  history  of  pregnancy. 

ARTICLE    IV. 

CHANGES   IN   THE   BREASTS. 

The  mammce,  which  must  also  be  considered  as  an  appendage  to  the  geni- 
tal organs,  undergo,  during  gestation,  some  modifications  preparatory  to  the 
accomplishment  of  the  great  function  to  which  they  are  destined  after  the 
accouchement ;  thus,  in  the  very  commencement,  most  women  find  their 
breasts  to  become  tender  and  larger,  and  with  some,  this  is  so  constant  a 
sign  that  they  do  not  hesitate  to  consider  themselves  pregnant  as  soon  as  il 
is  perceptible.  The  enlargement  is  frequently  attended  by  certain  pricking 
sensations  or  positive  pains,  sometimes  even  by  engorgements  of  the  axillan 
ganglia.  It  is  by  no  means  uncommon  for  the  swelling  to  diminish  towards 
the  fourth  or  fifth  month,  but  it  reappears  again  near  the  end  of  pregnancy, 
and  is  then  considerably  larger  than  before.  In  some  women  it  may  even 
be  carried  to  the  extent  of  producing  an  inflammatory  engorgement  of  its 
substance,  followed  by  an  abscess.  More  rarely,  the  breast,  which  was  at 
first  slightly  enlarged,  subsides,  and  remains  flaccid  and  soft  until  after  de- 
livery. In  general,  this  is  an  unfortunate  circumstance,  because,  from  the 
observations  of  my  friend,  Dr.  Donne,  such  women  prove  very  poor  nurses 
on  account  both  of  the  bad  quality  and  the  small  quantity  of  their  milk. 

[When  the  swelling  of  the  breasts  is  very  decided,  it  occasions  so  great  a  disten- 
tion of  the  skin  as  to  give  rise  to  markings  which  resemble  precisely  those  described 
upon  the  skin  of  the  abdomen.] 

About  the  end  of  the  second  month,  according  to  Mr.  Montgomery,  but 
in  my  opinion  a  little  later,  the  nipple  swells,  and  becomes  more  erectile, 
sensitive,  and  projecting ;  its  color  also  is  deeper.  The  surrounding  skin 
becomes  the  seat  of  a  larger  afflux  of  liquid,  and  assumes  an  almost  emphy- 
sematous appearance.  This  skin  is  also  discolored,  exhibiting  at  first  a  light 
yellowish  tint,  but  in  the  course  of  the  two  succeeding  months  the  areola  is 
completed,  and  the  skin  of  the  mamma  then  presents  the  following  charac- 
ters: A  circle  around  the  nipple,  the  color  of  which  varies  in  depth  of  shade 
according  to  the  individual,  being  generally  darker  in  persons  who  have 
black  hair  and  eyes,  and  in  brunettes,  than  in  blondes,  or  in  feeble  and 
delicate  women.  The  circle  is  from  three-quarters  of  an  inch  to  one  inch 
and  a  quarter  in  extent,  but,  like  the  intensity  of  the  discoloration,  it  in- 
creases with  the  advancement  of  gestation.  In  the  negress,  the  areola  like- 
wise becomes  darker. 


156 


PREGNANCY, 

Fig.  4" 


P B 

in  m 


.  \ ;*•>?:    ■   :k',J/;/;lil!0- 


s     ■  %  i  f    ^3| 

,  A.   Nipple.     B.  Sebaceous  tubercles  scattered  over  the  surface  of  the  true  areola.     C.  Spots  of  the  dotted 
areola.    D.  Markings  due  to  distention  of  the  skin.J 

|  Here  and  there  on  the  surface  of  the  areola  we  find  small  elevations  of  about 
one-sixteenth  to  three-sixteenths  of  an  inch,  due  to  an  hypertrophied  condition  of 
the  twelve  or  twenty  sebaceous  glands  already  described.  When  they  are  pressed, 
a  whitish  fluid  escapes  which  has  been  mistaken  for  milk. 

Toward  the  fifth  month,  another  areola,  known  as  the  secondary,  spotted  or  dap- 
pled areola,  is  formed  around  the  first  one.  It  extends  much  farther  than  the  first 
one,  often  covering  a  large  portion  of  the  skin  of  the  breasts.  When  this  spotted 
areola  is  examined  closely,  we  observe  that  the  pigmentary  coloration  does  not  cease 
suddenly  at  the  circumference  of  the  true  areola,  but  that  the  coloring  matter  is  so 
deposited  in  the  adjacent  skin  as  to  form  a  vanishing  layer  of  greater  or  less  extent 
in  different  women.  This  secondary  areola  is  sprinkled  with  a  considerable  num- 
ber of  small  white  spots  which  give  it  a  peculiar  appearance.  The  spots,  which 
have  a  rounded  form,  are  merely  so  many  points  devoid  of  pigment,  each  one  exhib- 
iting in  its  centre  a  small  black  spot  which  marks  the  orifice  of  a  sebaceous  gland 
and  the  position  of  a  minute  hair  discoverable  by  the  assistance  of  a  magnifier.] 

These  changes  usually  persist  during  lactation,  though  when  the  woman 
does  not  suckle  her  infant  they  diminish  after  delivery,  but  do  not  wholly 
disappear.  Consequently,  they  are  more  conclusive  in  primiparse  than  in 
others  ;  and  although  we  must  not  always  anticipate  their  existence  in  preg- 
nancy, yet,  whenever  they  are  fbu,nd,  they  constitute  an  almost  certain  sign 
of  that  condition.     (See  Diagnosis  of  Pregnancy.) 


ARTICLE  V. 

[iNATOMICAL    AND    FUNCTIONAL   CHANGES   OF    PARTS    NOT    IMMEDIATELY 
CONNECTED    WITH   THE   GENERATIVE   FUNCTION. 

The  entire  organism  is  deeply  affected  by  the  pregnant  condition.  Of  the 
changes  observable  some  are  purely  physiological  and  compatible  with  excellent 
health,  whilst  others  are  pathological.  Although  indispositions  and  diseases  so 
often  fall  to  the  lot  of  the  pregnant  female,  it  were  an  exaggeration  to  say  that 
pregnancy  ifl  a  disease  of  nine  months  duration.  Some  women  are  never  better 
than  when  p-egnant,  in  which  case  it  is  eminently  a  physiological  condition. 


ORGANIC     CHANGES     DURING     PREGNANCY.  157 

Although  it  is  difficult  to  draw  the  line  between  these  two  orders  of  phenomena 
we  have  nevertheless  endeavored  to  indicate  it  as  clearly  as  possible,  and  in  this 
intent  shall  study  at  present  only  such  anatomical  and  functional  changes  as  are 
observed  in  healthy  pregnant  females,  leaving  all  that  is  pathological  for  discussion 
in  another  part  of  the  work. 

\  1.  Digestion.     Nutrition. 

The  digestive  organs  are  almost  always  affected  by  pregnancy;  but  to  those 
functional  changes  which  are  familiar  to  all,  we  shall  add  a  description  of  some 
anatomical  alterations  of  more  recent  observation. 

Disturbances  of  Digestion.  —  Sometimes  immediately  after  impregnation  has  taken 
place,  the  digestive  function  indicates  by  unmistakable  signs  the  impression  pro- 
duced upon  it  thereby.  We  may  adopt  Professor  Pajot's  very  natural  classification 
of  these  changes,  namely,  stimulation,  depression,  disorder,  and  perversion. 

Stimulation  of  the  digestive  function,  says  this  author,  is  the  least  frequent  of 
these  classes,  though  it  sometimes  occurs.  The  appetite  is  then  greater,  digestion 
easier,  the  circulation  quicker,  the  face  of  a  fresher  color,  and  the  mucous  mem 
branes  redder. 

Depression  of  the  function  is  much  more  common,  and  is  indicated  by  some 
emaciation,  pallor,  and  alteration  of  the  features.  These  are  often  followed  by 
disorder  and  perversion  of  digestion,  vomiting  being  the  most  noticeable  phenomenon 
of  all.  Although  the  latter  classes  are  so  commonly  attendant  upon  the  pregnant 
condition  as  sometimes  to  have  a  real  diagnostic  value,  they  ought  nevertheless  to 
be  regarded  as  diseases,  and  studied  as  a  part  of  the  pathology  of  gestation. 

Fatty  Condition  of  the  Liver.  —  The  liver  is  found  to  be  increased  in  size  in  almost 
all  women  who  die  during  or  shortly  after  labor.  It  was  this  fact  which  first  drew 
my  attention  to  this  organ,  and  led  me  to  the  discovery  of  the  fatty  condition 
described  in  my  inaugural  thesis.  The  following  is  a  brief  statement  of  the  facts 
concerning  it.  The  color  of  the  hepatic  tissue  is  not  uniform,  its  substance  being 
sprinkled  with  minute  yellow  spots  so  numerous  as  to  give  it  the  appearance  of 
granite.  The  spots  also  seem  to  form  so  many  projecting  points,  of  a  size  varying 
from  that  of  a  pin's  head  to  that  of  a  millet-seed.  Sometimes  they  are  disseminated, 
at  others  aggregated,  forming  in  the  latter  case  little  insular  patches,  though 
sometimes  the  agglomeration  is  such  as  to  give  rise  to  a  yellow  spot  of  an  inch  <>r 
more  in  diameter.  This  appearance  is  not  limited  to  the  surface  of  the  liver,  but 
will  be  found  in  any  section  made  through  the  substance  of  the  organ. 

A  microscopic  examination  of  this  tissue,  made  in  connection  with  Dr.  Vulpian, 
exhibited  hepatic  cells  in  good  condition  mingled  with  an  abundance  of  fat  globules. 
A  fatty  condition  of  the  liver  in  pregnant  women  is  therefore  well  determined, 
although  its  causes  and  significance  are,  as  yet,  but  little  understood. 

\  2.  Circulation. 

Throughout  the  period  of  pregnancy,  but  especially  during  the  latter  half,  the 
fzeneral  circulation  becomes  more  active;  an  activity  which  modern  research  has 
shown  to  be  connected  with  important  changes  in  the  composition  of  the  blood  and 
with  hypertrophy  of  the  heart. 

Changes  in  the  Blood.  —  The  conditions  known  as  the  plethora  and  hydremia  of 
pregnant  women  have  been  successively  admitted  by  the  profession,  but  as  they 
involve  a  question  to  be  studied  in  connection  with  the  diseases  of  pregnancy,  we 
here  confine  ourselves  to  the  statement,  that  both  opinions,  though  perhaps  excep- 
tionally true,  are  equally  false  in  tin-  majority  of  cases.  Though  the  blood  lit 
altered  during  pregnancy,  we  sec  ii"  reason  for  regarding  the  alteration  as  any- 
thing more  than  a  physiological   phenomenon. 

To  MM.  Andral  and  Gavarret  is  due  the  honor  of  having  discovered  the  change? 


158  PREGNANCY. 

which  the  blood  undergoes  during  pregnancy,  and  their  investigations  have  been 
followed  up  by  Becquerel,  Rodier,  and  Regnauld.  As  the  experiments  of  all  these 
observers  coincide,  we  have  but  to  give  the  results  at  which  they  arrived.] 

Now,  if  we  admit  with.  MM.  Andral  and  Gavarret,  that  the  mean  normal 
proportion  of  corpuscles  is  127,  or  with  MM.  Becquerel  and  Rodier,  that  it 
is  141  for  men  and  125  for  women,  it  will  be  seen  that  all  the  analyses  made 
up  to  the  present  time  give  a  much  lower  mean  for  a  woman  at  an  advanced 
stage  of  her  pregnancy.  Thus,  of  34  bleedings  examined  by  Andral  and 
Gavarret,  but  one  specimen  exhibited,  at  the  end  of  the  second  month,  a 
proportion  of  corpuscles  greater  than  the  physiological  mean,  namely,  145. 
In  one  only,  pregnant  between  one  and  two  months,  did  the  corpuscles 
reach  the  physiological  standard  of  128.  In  all  the  remaining  32  cases  the 
corpuscles  were  below  this  point,  ranging  in  6  cases  from  125  to  120,  and 
in  the  other  26,  from  120  to  95. 

The  34  bleedings  gave  different  results  as  regards  the  fibrin,  the  mean 
physiological  proportion  of  which  is  3,  according  to  the  period  of  pregnancy 
at  which  the  blood  was  drawn.  Thus,  from  the  first  month  to  the  end  of 
the  sixth,  the  amount  of  fibrin  was  always  below  the  average ;  the  mean 
being  2-5,  the  minimum  1*9,  and  the  maximum  only  2-9.  During  the  last 
three  months,  on  the  contrary,  the  proportion  of  fibrin  exceeded  the  physio- 
logical average ;  it  was  about  4,  the  maximum  reaching  4'8.  Toward  the 
end  of  the  last  month,  the  average  is  4*3. 

MM.  Becquerel  and  Rodier  analyzed  the  blood  of  nine  pregnant  women, 
two  of  whom  were  20  years  of  age,  two  22,  one  25,  one  27,  one  29,  one  34, 
and  one  41. 

Five  of  these  were  of  robust  constitution,  two  were  about  the  average  in 
this  respect,  whilst  the  other  two  were  weak  and  apparently  lymphatic. 

Six  enjoyed  excellent  health,  two  were  not  so  well,  and  one  was  in  the 
hospital  on  account  of  indefinite  pains  in  the  abdomen,  and  a  cough  of 
rather  long  standing,  though  not  serious  in  character. 

One  was  4  months  pregnant,  four  5,  one  5 J,  one  6,  and  two  7., 

The  following  represents  the  average  composition  of  the  blood,  at  least  as 
regards  its  principal  elements :  — 

Corpuscles, 

Fibrin, 

Albumen, 

(The  average  in  ncn-pregnant  women  is  70-5.) 
Water,  .         .         .         .801-6 

(The  average  in  non-preguant  women  is  791-1.) 

My  colleague  and  friend,  M.  Regnauld,  has  the  following  table  in  his 
thesis,  and  I  think  it  so  important  that  I  give  it  entire:  — 


Average. 

Maximum. 

Minimum. 

111-8 

127-1 

87-7 

3-5 

4- 

2-5 

66-1 

68-8 

62-4 

ORGANIC     CHANGES     DURING     PREGNANCY. 


159 


Table  showing  the  Composition  of  1000  Parts  of  Blood  from  25  Women  at 
various  Stages  of  Pregnancy. 


s 

S 

a 

O 

J£ 

STAGES   OF   PREGNANCY. 

a  g 

3 

a 

£ 

a 

£ 

s 

p 

u 
o 
U 

2  I 

"3  ~ 

CO 

Water  and  v 

1.  2d  month,       .... 

20 

2-60 

70-50 

1 25-35 

11-75 

789-80 

2.  End  of  2d  month, 

21 

2-80 

70-18 

126-40 

9-30 

991-32 

3.  3d  month, 

32 

2  70 

67-30 

122  60 

10-20 

797-20 

4.  3  months, 

27 

1-98 

70-25 

126-22 

8-65 

792-60 

5.  3  months  \, 

18 

2-90 

68  09 

116-91 

11-40 

800-70 

6.  4  months, 

39 

2-40 

69-35 

12718 

10-50 

790-57 

7.  5  months, 

31 

2-43 

69-40 

123-90 

8-75 

795-52 

8.  6  months  £, 

29 

2-80 

68-85 

99  76 

10-50 

818-09 

9.  7  months, 

27 

3-25 

69-20 

120  40 

7-90 

799-25 

10.  7  months, 

35 

2-79 

6830 

107  92 

9-75 

811-24 

11.7  months, 

22 

3-20 

68  66 

118-40 

1020 

799-54 

12   7  months  h, 

23 

416 

69  18 

9941 

8  43 

818-82 

13.  End  of  7th  month, 

19 

330 

6907 

112-50 

965 

805-48 

14.  End  of  7th  month, 

25 

2-78 

65-43 

100  77 

10-20 

820-82 

15.  Beginning  of  the  8th  month, 

29 

3-31 

6618 

115-44 

9-43 

805-62 

16.  Beginning  of  the  8th  month, 

38 

3-74 

64-92 

9936 

11-20 

820-78 

17.  Beginning  of  the  8th  month, 

20 

4-16 

67-20 

103-10 

9-50 

815  74 

18.  8  months  £,     . 

22 

4-47 

66  82 

95-60 

10  95 

82216 

19.  9  months, 

25 

3-70 

68-25 

108  90 

9-85 

809-30 

20.  9  months, 

24 

4-89 

65-47 

91-40 

10-75 

827-49 

21.  9  months, 

33 

4-42 

66-38 

115-25 

9-24 

804-71 

22.  9  months, 

27 

3-69 

64  45 

90-20 

10-40 

881-26 

23.  9  months, 

25 

4-39 

65-80 

94-90 

11-65 

823  36 

24.  9  months, 

28 

3-86 

68-92 

102-80 

9-96 

814-46 

25.  9  months, 

26 

4-28 

66-27 

99-75 

9  80 

819-90 

The  table  shows,  evidently,  that,  conformably  with  the  results  already  men- 
tioned :  — 

1.  Corpuscles. — From  the  beginning  of  pregnancy,  the  proportion  of  cor- 
puscles is  sensibly  diminished ;  but  that,  though  the  diminution  is  small  for 
the  first  five  or  six  months,  since  it  yields  an  average  of  121 '04.  it  is  some- 
times considerable  in  the  second  half,  and  especially  at  the  end  of  gestation, 
at  which  period  the  average  is  104#49. 

2.  Fibrin. — The  proportion  of  fibrin  is  not  increased  in  the  blood  of 
pregnant  women  until  about  the  sixth  month,  but  from  that  time  it  increases 
until  delivery. 

3.  Albumen. — Like  MM.  Becquerel  and  Rodier,  M.  Regnauld  found  a 
decrease  of  albumen,  which  is  lowered  from  70-5,  the  physiological  standard 
in  the  non-impregnated  condition,  to  68*6  in  the  first  seven  months,  and  to 
66*4  in  the  two  last. 

4.  Water.  —  The  proportion  of  water  in  the  blood  increases  sensibly 
towards  the  end  of  the  ninth  month  ;  thus,  the  average  of  the  first  thirteen 
analyses,  corresponding  with  the  first  seven  months,  is  expressed  by  81601. 
and  that  of  twelve  bleedings  performed  during  the  two  last,  by  817'70. 


160  PREGNAXCY. 

We  would  also  add  with  M.  Regnauld,  that  not  only  is  the  serum  more 
abundant  relatively  to  the  fibrin  and  corpuscles,  but  that  it  contains  less 
solid  matter,  which  of  course  helps  to  increase  the  total  amount  of  water 
contained  in  the  blood. 

[If  the  blood  of  a  pregnant  female  be  examined  by  the  usual  mode  of  bleeding,  h 
contracted  and  buffy  clot  is  sometimes  obtained,  all  readily  explained  by  the  increase 
of  the  fibrin.  Still,  this  appearance  is  less  frequent  than  has  been  asserted,  and 
than  one  might  be  led  to  suppose  would  be  the  case.  Out  of  nearly  two  hundred 
bleedings  practised  at  an  advanced  period  of  gestation,  M.  Jacquemier  discovered 
the  buffy  coat  but  once  in  six,  and  even  then  its  thickness  was  very  slight.  The 
same  author  also  observed  that  most  of  the  women  whose  blood  was  buffed  had 
fever,  and  that  but  few  were  free  from  any  apparent  disease. 

The  increase  of  fibrin  in  pregnant  women  continues  for  a  certain  time  after  de- 
livery. None  of  these  facts  should  be  forgotten  whilst  studying  puerperal  diseases, 
for  without  them  one  would  lie  liable  to  explain  the  excess  of  fibrin  by  the  inflam- 
matory nature  of  the  disease,  whilst  it  is  only  the  expression  of  a  transient  physio- 
logical condition. 

The  causes  of  all  of  the  changes  in  the  blood  which  we  have  just  studied  elude 
our  research.  It  does  not  seem  to  us,  however,  unreasonable  to  suppose  that  the 
increase  of  fibrin,  by  rendering  the  blood  more  coagulable,  may  have  a  tendency 
to  lessen  the  hemorrhage  which  always  accompanies  delivery.  We  shall,  however, 
have  occasion  to  revert  to  this  subject.] 

Hypertrophy  of  the  Heart.  —  M.  Larcher,  long  ago  (1828),  called  atten- 
tion to  hypertrophy  of  the  heart  as  a  result  of  pregnancy;  and  quite  recently, 
in  a  paper  read  at  the  Academy  of  Sciences,  produced  new  observations  in 
support  of  his  opinion.  According  to  him,  the  walls  of  the  left  ventricle 
become  at  the  least  one-quarter,  and  at  the  most  one-third,  thicker  during 
the  latter  months  of  pregnancy  or  shortly  after  delivery  ;  the  right  ventricle 
and  the  auricles  preserving  their  normal  thickness.  He  considers  this  the 
cause  of  the  precordial  murmur  so  common  during  gestation,  and  the  con- 
sequence of  the  obstruction  to  the  flow  of  blood  towards  the  lower  extremi- 
ties, occasioned  by  the  development  of  the  womb. 

[Numerous  observations  by  M.  Blot,  confirm  those  of  M.  Larcher  which  have 
just  been  mentioned.  He  proved  their  correctness  both  by  measurement,  which  is 
always  very  difficult,  and  by  weight  determined  with  the  greatestcare.  The  results, 
which  he  has  obligingly  put  in  my  possession,  are  as  follows:  The  total  average 
weight  of  the  heart  in  20  cases  of  puerperal  women  was  about  9  oz.  38  gr.  tr., 
whilst  in  the  usual  state  the  heart  of  a  young  woman  weighs  but  from  7  oz.  to  7 
oz.  2  dr.  tr.  It  would  thus  appear  that  the  organ  gains  more  than  one-fifth  upon 
its  total  weight  during  pregnancy.  This  hypertrophy  affects  the  left  ventricle 
almost  exclusively,  and  is  remarkable  for  being  temporary  like  the  hypertrophy  of 
the  uterus.   (II.  Blot.) 

|    3.    CnANGES    IN    THE    URINE. 

The  urine  undergoes  great  alteration  during  pregnancy  —  so  that,  beside  glyco- 
suria, which  will  be  studied  in  connection  with  the  phenomena  observed  after  delivery, 
ami  albuminuria,  which  properly  belongs  to  the  diseases  of  pregnancy,  we  have 
now  to  treat  of  kyesteine  whose  presence  in  the  urine  appears  to  be  a  result  of  the 
oregnant  condition.] 


ORGANIC     CHANGES    DURING     PREGNANCY.  161 

Kyesteine. —  For  several  years  past  the  attention  of  a  number  of  physicians 
das  been  directed  to  the  peculiar  phenomena  exhibited  by  the  urine  of 
pregnant  women.  Thus,  M.  Nauche,  and  after  him,  Messrs.  Eguisier  and 
Tanchou,  in  France,  Dr.  Letheby  (London  Med.  Gazette,  December,  1841), 
and  Mr.  Stark  (The  Edinburgh  Med.  and  Surg.  Journal,  January,  1842), 
in  Great  Britain,  and  Dr.  Elisha  Kane,  in  America  {Am.  Journal  of  the 
Medical  Sciences,  July,  1842),  have  submitted  the  result  of  their  observa- 
tions to  the  public,  after  arriving  at  the  conclusion  that  pregnancy  may  be 
detected  by  the  inspection  of  the  urine  alone.  This  question,  however,  is 
not  of  such  recent  origin  as  many  seem  to  believe,  for  several  of  the  ancient 
authors,  Avicenna  in  particular,  had  previously  described  the  characteristics 
of  this  fluid  in  gestation,  and  their  writings  frequently  exhibit  a  special 
attention  to  the  subject.  But  we  may  add,  that  their  observations  were  far 
less  precise,  and,  in  fact,  had  become  altogether  forgotten,  when  M.  Nauche 
undertook  his  researches.  We  shall  now  present  the  principal  results  which 
have  been  recently  obtained. 

If  the  urine  of  a  pregnant  woman  be  received  in  a  wineglass,  and  then 
be  permitted  to  settle  in  a  light,  airy  place,  the  following  peculiarities  will 
be  observed:  When  first  excreted,  the  urine  is  acid,  whitish,  somewhat 
clouded,  and  of  a  nauseous  odor;  frequently  little  white  corpuscles,  readily 
distinguishable  by  a  glass,  are  held  in  suspension,  but,  in  a  few  moments, 
these  subside  in  the  form  of  cloudy  flakes,  either  on  the  bottom  or  sides  of 
the  glass,  the  urine  meanwhile  becoming  more  limpid  and  transparent. 
Agreeably  to  the  observations  of  Dr.  Kane,  this  primary  deposit  does  not 
always  occur,  nor  is  it  peculiar  to  the  pregnant  state,  for  it  cannot  be  dis- 
tinguished from  the  mucous  deposits  so  often  seen  in  the  ordinary  urine. 
No  change  is  visible  on  the  surface  during  this  period,  but,  in  the  course  of 
eighteen  or  twenty-four  hours,  a  number  of  small,  brilliant,  crystalline 
granules,  irregularly  isolated,  appear  there,  in  numerous  cases ;  and  in 
some  instances,  these  granulations  unite  so  as  to  constitute  a  thin,  trans- 
parent, and  iridescent  layer,  which  is  only  visible  in  certain  positions. 

The  urine  remains  in  that  state  for  several  days,  though  it  soon  begins  to 
manifest  the  peculiar  signs  of  gestation;  thus,  upon  the  second  day,  or 
during  the  course  of  the  third,  according  to  M.  Eguisier,  sometimes  sooner, 
but  rarely  later,  its  transparency  diminishes,  the  original  clouded  appear- 
ance returns  with  increased  intensity,  the  odor  becomes  stronger,  and  a 
pellicle  may  be  discerned  forming,  at  first  like  a  nebulous  streak,  but  soon 
acquiring  larger  dimensions.  All  of  these  characters  are  more  evident  on 
the  third  and  fourth  days,  and  some  small  debris  fall  from  the  pellicle  to 
the  bottom  of  the  glass.  By  the  fifth  or  sixth  day  the  pellicle  is  almost 
entirely  destroyed  ;  its  debris  precipitate  and  form  a  white  crust  upon  the 
sediment.  It  is,  however,  replaced  successively  by  new  pellicles  less  white 
than  the  former,  and  studded  with  minute  brilliant  points  having  a  crystal- 
line lustre;  a  greenish  tint  also  supplants  the  milky  appearance. 

In  the  succeeding  days,  as  the  evaporation  of  the  urine  progresses,  its 
turbidity  and  green  color  increase;  putrefaction  commences,  and  the  second 
pellicle  is  destroyed  to  give  way  in  its  turn  to  a  third,  which  resembles  more 
or  less  that  which  putrefaction  engenders  upon  ordinary  urine. 
11 


lUl?  PREGNANCY. 

Dr.  Kane,  who  has  ohserved  these  changes  almost  hourly,  furnisnes  the 
following  account  of  their  progress:  The  pellicle  appears  at  a  variable 
period  ;  I  have  seen  it  sometimes  at  the  end  of  thirty-six  hours  —  at  others, 
as  late  as  the  eighth  day;  it  is  scarcely  perceptible  at  first,  but  soon  a  light 
cloud  of  a  milky  or  bluish-white  appearance  is  seen  at  the  centre  or  sides 
oi  the  glass;  at  the  beginning,  in  some  cases,  it  is  uniformly  deposited  on 
the  surface,  constituting  there  a  transparent  layer,  which  becomes  more  and 
more  distinct;  at  other  times,  it  is  not  so  well  characterized  in  the  early 
,  presenting  only  a  tew  striated,  irregular  circular  lines,  resembling  a 
web,  but  these  strire  become  condensed,  and  about  the  fifth  day  are  resolved 
inio  a  true  pellicle.  It  now  presents  a  creamy,  opaline  layer,  of  a  light- 
yellow  color,  which  grows  thicker  and  thicker;  its  external  surface  is 
rendered  unequal  and  ragged  by  the  presence  of  small  granulations,  which 
are  whiter  in  color  and  crystalline.  The  pellicle  then  resembles  the  layer 
of  fat  that  floats  on  the  surface  of  cold  broth,  and  it  retains  these  characters 
for  a  long  time.  On  the  subsequent  days,  the  sides  of  the  glass  are  covered 
with  small  whitish  streaks,  varying  from  a  line  to  a  fourth  of  an  inch  in 
extent,  which  attest  the  descent  of  the  pellicle  during  the  evaporation. 
The  pellicle,  especially  when  thick,  gives  off  a  strong  cheesy  odor,  accord- 
ing to  Dr.  Bird,  and  thus  facilitates  the  diagnosis ;  but  Dr.  Kane  has 
verified  this  observation  in  only  seven  cases  out  of  twenty-five,  and  he  has 
not  remarked  that  any  relation  exists  between  the  thickness  of  the  pellicle 
and  the  intensity  of  the  odor. 

After  standing  for  several  days,  the  pellicle  seems  first  to  give  way  at  the 
centre,  and  fissures  extend,  somewhat  later,  from  this  point  toward  the  cir- 
cumference. Gradually,  small  particles  separate  from  the  debris  and  fall 
to  the  bottom  of  the  glass;  the  pellicle  thus  diminishes  in  thickness,  but  it 
seldom  disappears  altogether  before  the  putrefaction  of  the  liquid  takes 
place;  and  the  primary  deposit  at  the  bottom  is  thus  increased  by  all  the 
detached  portions  of  pellicle,  which  gradually  settle  down. 

The  substance  forming  the  pellicle  lias  been  denominated  kyesteine  (from 
xwjoii,  bcos,  gestation  i,  by  M.  Nauche.  The  globules,  held  in  suspension  when 
the  urine  is  excreted,  gradually  aggregate,  mount  to  the  surface,  and  con- 
Btitute  the  pellicle  above  described.  This  pellicle  rarely  fails  to  develop 
itself  in  the  urine  of  pregnant  women  ;  thus,  for  instance,  in  eighty-five 
cases  examined  by  Dr.  Kane,  it  appeared  in  sixty-eight  with  all  its 
charai  teristics,  in  eleven  it  was  not  well  marked,  and  in  six  only  it  failed 
to  appear.  One  of  the  last  six  had  a  mammary  abscess,  and  was  con- 
valescent from  typhoid  fever ;  another  was  very  much  enfeebled  by  pre- 
vious hemorrhages,  and  only  four  could  be  regarded  as  true  exceptions  to 
the  rule. 

Without  denying  the  existence  of  the  modification  which  we  are  studying, 
1  cannot  accept  the  opinion  of  the  American  accoucheur  in  regard  to  the 
frequency  of  its  occurrence.  With  the  view  of  determining  this  point,  I 
have  examined  the  urine  of  a  great  number  of  pregnant  females,  and  I  can 
v,  that,  although  it  did  present  the  characters  indicated  in  a  certain 
Dumber  of  cases,  yet  very  frequently,  and  especially  in  the  later  months. 
nothing  of  the  kind  was  discoverable, 


ORGANIC   CHANGES   DURING    PREGNANCY.  163 

I  confess,  also,  that  were  I  to  depend  upon  the  result  of  my  latest  inves- 
tigations, I  should  be  inclined  to  regard  the  existence  of  this  pellicle  as 
altogether  exceptional  in  the  last  six  weeks  of  gestation ;  for  I  have  exam- 
ined (September  and  October,  1849)  the  urine  of  fifteen  women  without 
observing  it.  I  do  not,  however,  forget  that  I  have,  in  former  years,  proved 
the  correctness  of  the  observations  of  my  predecessors,  and  I  am  unable  to 
explain  this  difference  in  the  result  of  experiments  performed  in  absolutely 
the  same  manner.  Can  it  be  due,  as  M.  Regnauld  supposes,  to  the  preser- 
vation of  its  acidity  much  longer  than  usual,  instead  of  becoming  alkaline 
within  two,  three,  or  four  days,  as  is  customary?  I  acknowledge  that  my 
attention  was  not  directed  to  this  point. 

The  urine  of  healthy  women  who  are  not  pregnant,  exhibits  nothing 
similar  to  this,  and  if  at  any  time  it  furnishes  a  pellicle,  it  has  not  the  dis- 
tinctive characters  of  kyesteine.  Some  years  ago,  it  was  my  custom  to  ex- 
amine comparatively  the  urine  of  non-pregnant  females,  which  I  placed  in 
the  same  kind  of  vessels,  and  under  the  same  conditions  of  temperature  and 
atmospheric  exposure ;  and  every  time  that  I  met  with  kyesteine  in  the 
urine  of  pregnancy,  that  of  the  other  woman  presented  nothing  similar. 

In  certain  pathological  conditions,  the  urine  is  sometimes  covered  with  a 
pellicle  which  might  prove  a  source  of  error,  though  some  authors  have 
pretended  to  be  able  to  distinguish  it  from  that  which  is  due  to  pregnancv. 
For  instance,  the  pellicle  which  occasionally  forms  on  the  urine  of  persons 
laboring  under  phthisis,  articular  diseases,  vesical  catarrh,  or  a  metastatic 
abscess,  does  not  appear  before  the  fifth  or  sixth  day,  that  is,  at  about  the 
period  when  putrefaction  begins,  and  having  once  commenced,  its  develop- 
ment is  completed  in  the  course  of  a  few  hours ;  whereas,  the  true  kyesteine 
appears  on  the  second  day,  is  then  developed  but  very  slowly,  and  apparently 
quite  independent  of  putrefaction.  Again,  this  latter  has  a  greater  specific 
gravity  than  that  produced  by  any  pathological  state  whatever. 

According  to  the  views  of  M.  Regnauld,  which  we  shall  give  shortly,  it 
will  be  seen,  that,  inasmuch  as  it  is  due  to  the  same  cause,  the  pathological 
pellicle  ought  to  present  the  same  characters,  and  that  writers  have  been 
deceived  as  to  the  value  of  the  different  signs  just  mentioned. 

The  chemical  characters  of  kyesteine  will  serve  to  distinguish  it  from  all 
the  mucous  or  albuminous  matters  found  in  the  urine.  These  properties, 
agreeably  to  M.  Eguisier,  are  nearly  all  negative;  thus,  it  is  neutral,  in- 
soluble in  alcohol,  ether,  water,  and  ammonia,  and,  unlike  albumen,  it  is 
not  soluble  in  alkaline  fluids,  nor,  like  mucus,  in  a  mixture  of  soap  and 
ammonia,  neither  in  boiling  alcohol  and  ether  like  fat.  Further,  the  urine 
containing  it  will  not  coagulate  by  boiling,  as  albuminous  urine  does,  but 
deposits  a  copious  white  powder  on  cooling ;  nor  will  it  coagulate  by  the 
addition  of  nitric  acid. 

Kyesteine  has,  however,  many  of  the  properties  of  these  substances;  for, 
being  evidently  of  an  organic  nature,  it  is  precipitated  by  the  deuto-chloride 
of  mercury,  by  most  strong  acids,  and  the  astringent  solutions.  Finally, 
in  the  present  state  of  our  knowledge,  it  must  be  regarded  as  a  new  sub- 
stance, which  is  considered  by  MM.  Bonastre  and  Nauche  as  gelatino- 
albuminous.  (Eguisier.)  We  shall  find  further  on,  that  the  researches  of 
M.  Regnauld  tend  to  establish  the  contrary. 


164  PREGNANCY. 

Although  writers  on  the  subject  agree  very  nearly  as  to  the  physical  and 
chemical  properties  of  kyesteine,  they  differ  widely  in  regard  to  its  micro- 
ecopical  characters.  Thus,  MM.  Eguisier,  Golding  Bird,  Kane,  and  Donn£ 
disagree  as  to  the  size,  form,  and  number  of  the  globules.  M.  Simon,  who 
has  very  frequently  subjected  the  pellicle  to  microscopic  examination,  gives 
the  following  as  the  result  of  his  researches.  It  is  found  to  contain  the 
following  elements:  1,  an  amorphous  matter,  formed  of  small  opaque  points; 
2,  numerous  vibriones  in  active  motion  ;  3,  crystals  of  ammoniaco-magnesian 
phosphate;  4,  if  the  examination  be  made  at  a  still  later  period,  it  will  con- 
tain an  abundance  of  monads. 

The  most  difficult  point  of  the  subject  to  determine  is  the  following:  To 
what  is  the  presence  of  kyesteine  in  the  urine  of  pregnant  females  to  bo 
attributed  ? 

After  having  endeavored  to  prove  that  it  could  not  result  from  a  par- 
ticular action  in  the  kidney,  from  the  functional  derangement  of  the  respi- 
ratory apparatus,  from  any  modification  whatever  in  the  digestive  action,  or 
from  the  new  functions  of  the  mammary  glands,  M.  Eguisier  concluded  that 
it  must  be  owing  to  the  passage  of  the  amniotic  liquor,  or  a  part  of  its  ele- 
ments, into  the  urine,  and  he  thought  that  the  two  following  propositions 
(which  are  more  fully  detailed  in  his  memoir)  proved  the  correctness  of 
his  conclusions  in  a  satisfactory  manner,  namely : 

A.  There  is  a  continual  exhalation  and  absorption  going  on  upon  the 
external  face  of  the  amnios,  the  products  of  which  are  removed  from  the 
organism  through  the  urinary  passages. 

B.  The  admixture  of  a  certain  quantity  of  the  liquor  amnii  with  the  urine 
of  a  healthy  person,  not  pregnant,  confers  upon  it  many  of  the  properties  of 
kyesteinic  urine. 

The  truth  of  this  proposition  being  admitted,  it  readily  explains,  he  says, 
1,  why  the  urine  only  begins  to  be  charged  with  it  at  a  period  when  the 
amniotic  liquor  is  abundant  enough  for  us  to  suppose  that  its  passage  into 
the  urine  would  be  appreciable ;  2,  why  the  kyesteinic  characters  are  not  so 
evident  at  the  end  of  gestation,  a  period  when  the  liquor  amnii  is  less 
abundant,  or  less  charged  with  animal  matters ;  and  3,  why  they  suddenly 
disappear  after  the  evacuation  of  the  waters. 

But  Dr.  Kane  does  not  admit  this  explanation,  plausible  as  it  seems ;  for 
he  believes  that  the  kyesteine  is  intimately  associated  with  the  lacteal  secre- 
tion, and  appears  to  attribute  it  to  an  admixture  of  milk  with  the  urine. 
"  In  fact,"  he  continues,  "  I  have  frequently  proved  the  presence  of  kyesteine 
in  the  urine,  at  different  periods  of  lactation,  notwithstanding  the  formal 
proposition  of  M.  Eguisier;  for  in  forty-four  nursing  women,  out  of  ninety- 
lour,  the  perfect  kyesteinic  pellicle  was  developed,  with  all  the  characters 
it  exhibits  during  gestation  ;  and  it  was  nearly  always  in  those  cases  where 
the  flow  of  milk  is  limited,  or  rendered  difficult  by  some  particular  circum- 
stance, and  in  which  the  breasts  were  consequently  more  or  less  engorged, 
that  kyesteine  appeared  in  the  urine;  but  it  was  found  much  more  rarely 
whenever  the  mother  nursed  her  infant,  and  her  breasts  were  properly 
drawn.  In  a  word,"  says  Dr.  Kane,  "the  existence  of  kyesteine  during 
pregnancy,  and    even    after  the  accouchement,  up  to  the  establishment  of 


ORGANIC     CHANGES     DURING     PREGNANCY.  165 

the  mammary  secretion  ;  its  rare  existence  during  lactation,  and  its  reappear- 
ance, when  the  latter  is  suspended  or  impeded,  at  the  time  of  weaning,  for 
instance,  establish  an  intimate  relation  between  the  functions  of  the  mamnue 
and  the  kyesteinic  urine."  Golding  Bird,  Simon,  and  Lehman  entertain 
nearly  similar  views. 

An  attentive  study  of  the  facts  pertaining  to  this  subject  has  led  my 
colleague  and  friend,  M.  Reguauld,  to  the  following  opinion : 

Normal  urine  holds  in  solution  a  certain  amount  of  azotized  matter, 
originating,  probably,  in  an  incomplete  combustion  of  albuminous  sub- 
stances, which  in  the  blood  are  transformed  into  uric  acid,  or,  by  a  higher 
degree  of  oxygenation,  into  urea. 

Now  we  may  readily  assure  ourselves,  that  during  pregnancy  there  is  a 
hyper-secretion  by  the  kidney  of  an  analogous,  if  not  of  an  identical 
matter;  and  it  is  to  the  action  of  the  air  upon  this  azotized  matter  in  its 
abnormal  proportions,  that  the  several  phenomena  before  described  appear 
to  be  due. 

The  first  cloudiness  of  the  fluid  is  due  to  the  separation  of  carbonate  of 
lime,  formed  by  the  reciprocal  reaction  of  the  carbonate  of  ammonia,  re- 
sulting from  the  decomposition  of  the  urea,  and  of  the  phosphate  of  lime 
which  already  existed  in  the  urine.  In  proportion  as  the  decomposition 
giving  rise  to  ammonia  progresses,  the  fluid  loses  its  acidity,  until  the  bril- 
liant crystals  of  ammoniaco-magnesian  phosphate,  which  are  so  readily 
recognized  by  microscopic  examination,  begin  to  appear  upon  its  surface. 

It  is  singular,  that  whilst  these  reactions  are  going  on,  such  a  multitude 
of  microscopic  animalcules  (vibriones)  should  be  developed  in  the  urine 
as  to  cause  the  whitish  layer,  when  examined  with  a  proper  magnifying 
power,  to  seem  composed  entirely  of  them,  in  connection  with  crystals  of 
ammoniaco-magnesian  phosphate. 

In  order  to  prove  that  the  formation  of  the  pellicle  of  which  we  are 
speaking  is  really  due  to  the  action  of  the  oxygen  of  the  air  upon  one  of 
the  elements  of  the  urine,  it  will  only  be  necessary  to  observe  what  takes 
place  in  two  equal  quantities  of  the  same  urine,  one  of  which  is  exposed  to 
the  air,  whilst  the  other  is  removed  from  its  influence  by  being  placed  in 
an  atmosphere  of  hydrogen,  of  carbonic  oxide,  &c.  The  first  will  present 
the  characters  described,  whilst  the  other  will  exhibit  no  such  phenomena. 

M.  Reguauld  does  not  regard  these  properties  of  the  urine  as  due  to  a 
special  matter  contained  in  it,  but  as  a  consequence  of  the  presence  of  an 
over-proportion  of  an  element  which  is  common  to  all  urine;  whence  it 
seems  reasonable  to  suppose,  that  this  excess  of  azotized  matter  might 
exist  under  other  circumstances,  and  then  give  rise  to  the  same  phenomena. 
The  period  at  which  the  kyesteine  appears  in  the  urine  of  pregnant 
women,  is  stated  by  writers  to  be  exceedingly  variable.  M.  Eguisier  says 
that  the  characters  which  we  have  described  usually  begin  to  show  them- 
selves in  the  course  of  the  second  month,  and  acquire  their  greatest  devel- 
opment from  the  third  to  the  sixth  month;  after  the  seventh,  they  generally 
decline  until  the  end  of  gestation,  so  that  in  the  course  of  the  ninth,  and 
sometimes  even  of  the  eighth  month,  they  are  hardly  more  marked  than  in 
the  second.     M.  Tanchou  has  observed  them  in  women  who  bad  missed 


166  PREGNANCY. 

their  courses  but  once.  Dr.  Kane  saw  them  on  one  occasion  before  the 
fourth  wetk,  once  before  the  fifth  week,  and  often  before  the  end  of  the 
third  month.  (Dr.  Elisha  Kane,  American  Journal  of  the  Med.  Sciences, 
July,  1842.) 

I  think  that  the  facts  which  I  have  observed,  and  the  details  which  I 
have  given,  justify  the  following  conclusions: 

1.  That  the  pellicle  described  by  Nauche  is  not  composed  of  a  matter  of 
new  formation. 

2.  That  it  is  due  to  an  over-secretion  of  azotized  matter  which  exists  in 
email  quantity  in  normal  urine,  and  to  the  action  of  the  atmospheric  oxygen 
upon  it. 

3.  That  it  is  far  from  being  always  present  at  any  period  of  the  preg- 
nancy, and  that  it  is  very  rare  in  the  latter  months. 

4.  That  it  may  appear  in  certain  pathological  conditions,  and  then  differs 
in  no  respect  from  that  which  is  observed  during  pregnancy. 

\l  4.  Osteophytes  of  the  Cranial  Bones. 

There  is  formed  during  pregnancy,  and  may  be  found  after  delivery,  between 
the  internal  table  of  the  bones  of  the  skull  and  the  external  surface  of  the  dura 
mater,  a  newly-formed  product  which  is  at  first  fluid,  but  grows  gradually  denser 
and  finally  ossifies,  thus  adding  to  the  thickness  of  the  cranial  walls.  At  first  it 
forms  plates  of  a  spongy  tissue  inclosed  between  two  compact  layers.  At  a  later 
period  the  plates  are  no  longer  separate  but  unite  so  as  to  form  a  supernumerary 
bony  arch  covering  the  entire  dura  mater,  but  growing  thinner  as  it  approaches  the 
occipital  foramen  to  which  it  finally  extends. 

M.  Ducrest  describes  it  as  follows.  I  examined  the  surface  of  the  cranium  of 
231  women  who  died  in  the  puerperal  state,  and  of  these  90,  or  more  than  one- 
third,  presented  the  osteophyte.  The  researches  of  M.  Alexis  Moreau,  Interne 
of  the  Maternity  Hospital,  give  a  still  larger  proportion.  Out  of  40  crania,  he 
found  that  27  presented  it  to  a  greater  or  less  degree.  On  the  other  hand,  not  one 
of  71  cases,  35  being  male  and  3G  female,  whose  death  had  no  connection  with 
pregnancy,  examined  either  by  M.  Cossy,  hospital  Interne,  or  by  myself,  afforded 
a  single  instance  of  the  affection. 

To  which  then,  of  these  three  conditions  (pregnancy,  the  puerperal  state,  or 
puerperal  disease)  can  the  production  of  the  osteophyte  be  referred?  Sixteen  of 
the  women  who  had  it  died  between  three  and  seventy-two  hours  after  delivery,  and 
in  several  of  these  the  plates  extended  throughout  the  whole  extent  of  the  cranium, 
ami  resisted  the  edge  of  the  scalpel  almost  as  much  as  the  original  bone.  It  were 
difficult  to  suppose  that  such  extensive  formations  could  have  originated  and 
acquired  an  almost  bony  hardness  in  so  short  a  time  as  two  or  three  days. 

As  this  objection  applies  equally  to  the  puerperal  condition  and  to  the  diseases 
of  which  the  women  died,  pregnancy  would  appear  to  be  the  only  cause  of  its 
development.     (Ducrest.     Theses  de  Paris,  1844,  No.  12.) 

An  anatomical  alteration  such  as  this,  appearing  under  the  influence  of  preg- 
nancy ami  afterward  disappearing,  is  certainly  very  curious.  Though  we  may  fail  to 
determine  its  causes  and  importance,  its  existence  is  sufficiently  proved.  It  had 
been,  indeed,  already  described  by  Professor  Kokitansky  of  Vienna,  who  also 
regarded  it  as  peculiar  to  gestation  and  not  as  a  pathological  condition. 

{  5.  Pigmentary  Deposits 

We  have  already  stated  that  the  breasts  acquire  during  pregnancy  a  much  larker 
brown  color.     Other  regions  then  also  receive  a  deposit  of  coloring  matter.     Thus 


OF    THE    DECIDUA.  167 

many  -women  will  have  on  the  median  line  of  the  abdomen  a  brown  streak  as  dark 
as  the  areola,  from  the  T's  to  the  J  of  an  inch  in  width,  extending  from  the  tnons 
veneris  to  the  umbilicus,  and  sometimes  even  to  the  xyphoid  appendage.  This  line, 
drawn  as  with  a  brush,  as  M.  Pajot  expresses  it,  is  especially  marked  in  brunettes, 
in  whom,  indeed,  it  is  not  uncommon  to  find  the  entire  skin  of  the  abdomen  and 
of  the  upper  part  of  the  thighs  of  a  deep  bistre-like  hue,  and  sprinkled  with  little 
white  spots  precisely  resembling  those  of  the  dotted  areola. 

The  perineum  also,  and  the  labia  majora  almost  always  have  a  darker  browr 
color  during  pregnancy. 

In  connectic-n  with  these  normal  colorations,  we  might  mention  other  spots  which 
appear  more  especially  upon  the  face;  but  as  they  appear  to  us  rather  of  a  patho- 
logical character,  we  defer  their  description  to  a  later  period.] 


CHAPTER  III. 

OF   THE   DECIDUA. 

[The  study  of  the  decidua  intervenes  naturally  between  the  history  of  the  changes 
undergone  by  the  maternal  organs  and  that  of  the  development  of  the  ovum.  It  is 
now  admitted  that  the  decidua  is  formed  of  the  uterine  mucous  membrane  which 
undergoes  changes,  and  becoming  detached  from  the  womb  adheres  so  closely  to 
the  surface  of  the  ovum  as  to  be  expelled  with  it  during  labor.  Although  at  the 
outset  it  belongs  to  the  mother,  it  is  at  the  last  a  mere  appendage  of  the  ovum. 

Before  giving  the  most  recent  description  of  the  decidua,  it  will  be  necessary  to 
state  the  old  and  generally  accepted  theory  concerning  it,  at  the  same  time 
endeavoring  to  indicate  the  cause  of  the  erroneous  views  entertained  by  almost  all 
who  have  investigated  its  history.] 

The  Old  Theory. — If  an  ovum  which  has  been  expelled  intact  in  con- 
sequence of  an  abortion  within  the  first  two  months  be  examined,  it  will  be 
found  surrounded  by  a  sort  of  pouch  with  which  it  lies  in  contact  by  nearly 
four-fifths  of  its  external  surface,  whilst  the  other  fifth  is  free,  and  provided 
with  the  floating  villi  developed  upon  the  vitelline  membrane,  known  as 
the  villi  of  the  chorion. 

This  pouch,  which  is  pyriform  in  shape,  like  the  uterine  cavity  upon 
which  it  seems  to  be  moulded,  generally  presents  but  a  single  opening, 
situated  at  the  apex  of  the  cone,  which  it  represents,  and  evidently  corre- 
eponding  to  the  orifice  of  the  neck  of  the  uterus;  sometimes,  however,  I 
have  found  it  perforated  on  at  least  one  side  at  the  point  corresponding  lo 
the  opening  of  the  Fallopian  tubes. 

The  walls  of  this  pouch  are  formed  by  a  membrane  known  to  embryolo- 
gists  as  the  decidua.  It  has  two  surfaces,  one  external  and  the  other 
internal.  The  internal  surface  is  smooth,  covered  with  epithelium,  and 
when  examined  with  a  Ions,  presents  small  elevations,  in  form  not  unlike 
the  circumvolutions  of  the  cerebrum,  and  each  furnished  with  several  oval 
openings.  The  cavity  limited  by  this  Burface  sometimes  contains  a  mucn- 
albuminous  fluid,  and  in  certain  pathological  cases,  fluid  or  coagulated 
blood,  though  ordinarily  they  do  not  exist  in  it. 

The  external   surface  of  the  decidua   may  be  divided   into  two  portions. 


163  PREGNANCY. 

the  smaller  of  which  is  in  contact  with  the  ovum,  and  surrounds  the  greatei 
part  of  its  external  surface ;  the  other,  and  by  far  the  larger  portion,  is 
entirely  free,  and  must,  when  the  ovum  was  still  within  the  uterus,  have 
been  applied  to  the  internal  surface  of  the  womb.  This  external  surface  is 
very  irregular,  and  thickly  studded  with  small  and  tender  filaments. 

The  portion  of  this  membrane  in  contact  with  the  ovum,  was  at  first 

termed  the  ovular  decldua,  and  afterwards,  as  suggestive  of  the  way  in  which 

it  was  supposed  to  be  formed,  the  decidua  reflexa;  the 

Fl°- 50-  other  was  called    the  uterine  or  parietal  decidua,  on 

account  of  its  relation  with  the  wall  of  the  uterus. 

Now,  what  is  the  nature  of  this  membrane?  What 
is  the  mode  of  its  formation?  At  what  period  is  it 
developed?  To  furnish  replies  to  these  questions  the 
following  theory  was  imagined,  which  theoretically 
furnishes  quite  a  good  solution  of  all  the  difficulties  of 
the  case. 

a  section  of  the  womb         As  previously  stated,  the  uterus,  like  all  the  other 
ex  11  .ltins  t  e  era  na  in    geujtal   organs,  becomes   the  seat   of  a   more   active 

ittu,  before  the  arrival  of      &  to  > 

the  ovum  (ow  theory),  vitality  immediately  after  a  fruitful  coition  ;    in  con- 

b  b.  Orificwof  ilia  Ea\u>  sequence  of  which   the  blood  flows  there  in  increased 

pian  tubes,    c.  The  de-  quantity,  occasioning  a  congestion  and  turgescence  of 

m,„u^    i"'  The  cayity  °f  tissue,  not  far  removed  from  inflammation.     This  ab- 

the  deciduous  meiiiurane.  ' 

normal  excitement  is  always  accompanied  by  the  secre- 
tion of  coagulable  lymph,  a  sero-albumiuous  fluid,  which  soon  fills  up  the 
uterine  cavity.  In  the  course  of  a  few  days  the  fluid  thickens,  and  its 
exterior  particles,  by  becoming  more  consistent,  form  a  soft  pulpy  mem- 
brane, which  lines  the  whole  internal  surface  of  the  womb ;  thereby  con- 
stituting a  true  sac,  that  is  in  contact  externally  with  the  mucous  mem- 
brane throughout,  and  is  filled  by  the  uncoagulated  portion  of  the  fluid. 
From  its  position,  this  pouch  must  evidently  assume  the  shape  of  the  uterine 
cavity  upon  which  indeed  it  seems  to  be  moulded  (Fig.  50). 

The  fecundated  ovule  does  not  reach  the  cavity  of  the  womb  until  after 
the  lapse  of  eight,  ten,  or  even  twelve  days,  from  the  time  of  fecundation, 
but  the  membrane  just  spoken  of  begins  to  form  much  earlier.  The  con- 
sequence is,  that  after  the  ovule  has  traversed  the  tube,  it  finds  the  internal 
orifice  closed  by  the  decidua,  and  evidently  can  only  pass  between  it  and 
the  uterus  by  pushing  the  membrane  before  it.  From  this  time,  the  decidua 
piesents  two  distinct  layers,  the  most  extensive  of  which  lines  the  internal 
surface  of  the  uterus,  except  at  the  point  occupied  by  the  ovum ;  it  is  called 
the  external  or  uterine  decidua.  The  other,  which  is  pressed  inward  by  the 
ovule,  and  is  therefore  in  contact  with  a  greater  or  less  extent  of  its  external 
Burface,  is  termed  the  internal  or  rejlexed  decidua,  the  ovular  decidua,  and 
the  epichorion  of  Chaussier. 

These  two  layers  are  at  first  widely  separated  from  each  other;  but  as 
the  ovum  increases  in  size,  the  extent  of  the  reflected  decidua  is  necessarily 
augmented  and  the  cavity  diminished,  so  that  by  the  fourth  month  the 
latter  has  disappeared,  and  the  parietal  and  ovular  layers  come  in  contact. 

The  ovum  is  in  immediate  contact  with  the  uterine  mucous  membrane 


OF    THE    DECIUUA. 


169 


k\ 


^ I 

The  decidua  after  the  arrival  of 
the  ovum  (old  theory),  c.  The 
external,  or  uterine  decidua.  E  E. 
The  internal  or  reflexed  layer. 
D.  The  cavity  of  the  decidua.  F 
The  chorion.  G.  The  amnion.  The 
other  references  the  same  as  in 
the  preceding  figure. 


by  a  small  part  of  its  surface ;  all  the  rest  of  its  external  surface  beiDg 
separated  from  it  by  the  reflexed  layer,  the  cavity, 
and  the  parietal  layer  of  the  decidua.     All  the  Fl°- 51- 

villi    of    the   ovum    which   are   covered   by   the  ^^^^^^^^_ 

decidua,  after  a  time  become  atrophied  and  dis- 
appear; but  those  which  are  in  immediate  contact 
with  the  uterus  become  greatly  developed,  and  con- 
tract more  or  less  intimate  connections  with  the 
innermost  layer  of  the  womb,  at  the  point  where 
subsequently  the  placenta  will  be  developed. 

We  see  that  thus  far  this  hypothesis  coincides 
very  ingeniously  with  the  appearances  presented 
by  ova  which  have  been  expelled  uninjured  by 
abortion.  It  enables  us  to  understand  perfectly 
how  that,  notwithstanding  the  complete  integrity 
of  the  decidua,  the  ovum  is  yet  covered  by  it  in 
but  a  part  of  its  extent. 

Subsequently,  however,  at  the  autopsies  of 
women  who  died  in  the  third  or  fourth  months  of 
gestation,  a  membrane  was  discovered  upon  the 
external  surface  of  the  placenta,  resembling  precisely  the  parietal  decidua, 
and  continuous  with  it,  without  there  being  any  discoverable  line  of  demarca- 
tion between  it  and  this  inter-utero-placental  membrane;  so  that  this  uterine 
decidua,  which  in  aborted  ova  was  in  contact  with  but  a  portion  of  the 
surface  of  the  ovum,  was  found  to  surround  it  completely,  as  the  shell 
incloses  the  egg  of  a  bird,  when  opportunity  offered  for  examining  it  in  situ 
in  the  uterus.1  This  apparent  contradiction  with  the  theory  was  accounted 
for  by  the  following  hypothesis. 

The  arrival  of  the  ovule  does  not  at  once  suspend  the  former  secretion  in 
the  uterus ;  and  it  continues  to  go  on,  more  particularly  from  the  surface 
that  is  directly  in  relation  with  the  ovum,  in  consequence  of  the  greater 
vitality  which  the  latter  maintains ;  and  the  secreted  matter,  being  precisely 
similar  to  that  which  formed  the  primitive  decidua,  thickens  in  turn,  thereby 
constituting  a  layer  of  plastic  material,  precisely  like  the  first,  between  the 
ovum  and  the  womb,  which  bathes  both  the  chorial  and  the  uterine  villosi- 
ties;  and  when  this  deposit  finally  coagulates,  it  contributes  to  the  forma- 
tion of  the  placental  mass,  the  external  surface  of  which  is  in  this  manner 
necessarily  covered  by  an  albuminous  layer.  This  lamina  has  been  called 
the  secondary,  or  the  inter-utero-placental  decidua  (decidua  serotina).  Al- 
though limited  at  first  to  the  external  surface  of  the  placenta,  it  soon  unites 
bo  intimately  with  the  uterine  layer  of  the  primitive  decidua,  that  their 
separation  becomes  quite  difficult  at  a  more  advanced  period. 

1  In  1851,  I  exhibited  to  the  Academy  of  Medicine,  and  afterwards  presented  to  M. 
Coste,  who  has  bad  it  engraved  in  his  great  Alias,  an  aborted  ovum,  presenting  a  per- 
fect decidua,  surrounding  the  ovum  as  the  shell  Burrounds  the  egg  of  a  bird,  The 
examination  of  this  ovum  revealed  an  arrangement  entirely  similar  to  what  will  be 
described  hereafter  from  specimens  observed  in  the  uterus.  This  is,  I  believe,  the 
first  perfect  aborted  ovum  which  lias  ever  been  studied. 


L70  PREGNANCY. 

According  to  this  view,  the  decidua  serotina  and  the  primitive  Je  idua 
have  a  common  origin  and  texture,  and  only  differ  a3  regards  the  time  of 
their  formation. 

In  adding,  finally,  that  the  decidua  was  by  some  supposed  to  be  destitute 
of  vessels  (anhistous  membrane  of  Velpeau),  whilst  others  considered  it  m 
be  perforated  and  traversed  by  arteries  and  veins  in  considerable  number, 
we  shall  have  briefly  reviewed  the  most  generally  received  opinions  upon 
this  subject. 

With  the  exception  of  some  disagreement  in  regard  to  unimportant  details, 
all  authors  were  unanimous  as  respects  this  capital  fact,  namely,  that  the 
decidua  is  a  newly-formed  membrane  superadded  to  the  uterine  mucous  mem- 
brane, from  which,  however,  it  is  entirely  distinct.  So  evident,  indeed,  did 
this  fact  appear,  that  no  one,  notwithstanding  the  old  assertions  of  Sabatier, 
Mayer,  Seiler,  and  Weber,  could  bring  himself  to  admit  that  the  decidua 
was  only  a  development  of  the  lining  membrane  of  the  uterus.  And  even 
at  the  present  time,  notwithstanding  the  numerous  preparations  of  M.  Coste 
(1842),  who  was  the  first  to  sustain  the  truth  of  this  proposition  in  France, 
many  honest  minds  still  hold  to  the  theory  of  Hunter,  which  I  myself 
supported  so  long. 

In  the  second  edition  of  this  work,  after  having  stated  the  opinions  which 
have  been  successively  advanced,  respecting  the  origin,  nature,  and  mode  of 
development  of  the  decidua,  I  said :  "  I  have  examined,  with  M.  Coste, 
several  of  the  preparations  on  which  he  relies  for  the  support  of  his  view, 
that  the  decidua  is  nothing  else  than  the  uterine  mucous  membrane  itself, 
which  is  hypertrophied  by  the  progress  of  gestation  ;  unfortunately  the  ovum 
in  all  of  them  had  advanced  to  the  third  month  at  least,  and  it  seems  to  me 
that  the  question  can  only  be  determined  when  an  opportunity  shall  be 
afforded  of  examining  an  ovum  of  not  more  than  five  or  six  weeks.  I  am, 
therefore,  far  from  having  a  settled  conviction,  though  I  am  willing  to  con- 
fess that  the  last  uterus  examined  by  us  together,  has  singularly  shaken  my 
belief  on  this  point  of  ovology  ;  and  this,  conjoined  with  the  descriptions 
given  by  Weber  and  Sharpey,  restrains  me  from  speaking  with  the  same 
degree  of  confidence  as  formerly.  I  therefore  think  it  a  question  requiring 
further  examination."    (Page  176,  trans,  of  2d  edition.) 

My  desires  expressed  in  1844  have  been  realized  ;  and,  thanks  to  the  kind- 
ness of  M.  Coste,  I  have  had  the  opportunity  of  examining  an  admirable 
collection  of  specimens  of  all  ages,  which,  I  take  the  opportunity  of  acknowl- 
edging, have  not  left  the  remotest  doubt  in  my  mind,  at  least  as  regards  the 
principal  fact.  I  therefore  reject  the  more  or  less  ingenious  hypotheses  pro- 
posed hitherto,  —  hypotheses  which,  it  is  true,  were  rendered  very  probable 
by  the  examination  of  a  large  number  of  ova  expelled  by  abortion,  —  and 
with  the  sincerest  conviction  of  its  truth  adopt  the  opinion,  that  the  decidua 
is  nothing  else  than  the  hypertrophied  mucous  membrane.  The  evidence 
of  anatomical  demonstration  is  not,  however,  to  be  resisted,  and  I  doubt  not 
that  all  who,  like  myself,  shall  have  studied  the  beautiful  preparations  at 
the  College  of  France,  will  be  convinced  of  the  error  of  their  views.  For 
the  benefit  of  those  who  may  not  have  the  good  fortune  to  see  these  prepara- 


OF     THE     DECIDUA.  171 

tions,  I  tliiiiK  it  proper  to  give  further  on  the  description  and  the  figure 
borrowed  from  the  magnificent  atlas  which  he  is  publishing. 

Present  Theory  of  the  Decidua. —  The  history  of  tbe  decidua  is,  at  the 
present  time,  merely  a  continuation  of  the  account  of  those  modifications  of 
the  uterine  mucous  membrane,  the  study  of  which  was  oegun  whilst  treat  lug 
of  menstruation.  They  are,  in  fact,  so  intimately  connected,  that,  in  order 
to  understand  what  remains  to  be  said  on  the  subject,  it  is  necessary  to 
recall  the  condition  of  the  mucous  membrane  of  the  uterus  at  the  menstrual 
period. 

Whilst  the  evolution  of  the  ovarian  vesicle  is  going  on  in  the  ovary,  the  vas- 
cularity of  the  uterine  mucous  membrane  is,  as  we  have  stated  (p.  95),  greatly 
increased,  and  the  highly  congested  vessels  are  discoverable  beneath  the 
epithelium.  The  utricular  glands  also  become  visibly  enlarged.  By  this 
development  of  its  principal  elements,  the  mucous  membrane  is  so  thickened, 
that  in  consequence  of  its  restriction  to  the  small  cavity  of  the  uterus,  it  is 
thrown  into  folds  and  circumvolutions  of  variable  depth,  which  are  espe- 
cially well  marked  at  the  angles,  and  give  forth  secondary  ramifications 
from  the  sides,  so  as  to  occasion  some  uniformity  of  appearance.  This  state 
of  turgescence,  and  the  violet  hue  which  often  accompanies  it,  is  main- 
tained, in  a  greater  or  less  degree,  until  the  ovule  is  discharged  ;  it  dimin- 
ishes during  the  last  days  of  the  menstrual  period,  and  disappears  almost 
entirely  some  time  after  the  catamenia  have  ceased. 

But  if  the  ovule,  before  leaving  the  ovarian  vesicle,  or  during  its  passage 
through  the  tube  towards  the  cavity  of  the  womb,  receive  the  vivifying 
influence  of  the  spermatic  fluid,  the  fecundation  will  maintain  and  increase 
the  abnormal  excitement  of  the  genital  organs,  produced  by  the  simple  de- 
velopment of  the  Graafian  vesicle.  Then,  instead  of  subsiding,  the  uterine 
mucous  membrane  becomes  still  more  turgescent,  and  of  a  deeper  violet  color, 
and  the  folds  and  wrinkles  increase  so  as  to  more  than  fill  the  cavity  of  the 
organ.  Its  vessels  are  engorged  and  distended  to  such  a  degree  as  to  cause 
small  effusions,  which  are  perceptible  beneath  the  epithelium,  and  also  to 
produce  ecchymosis,  which  give  to  the  internal  surface  of  the  uterus  a  striking 
marbled  appearance. 

Notwithstanding  this  great  turgescence,  the  internal  surface  of  the  mucous 
membrane  is  smooth  and  polished,  and  never  presents  the  villous  projections 
described  by  Baer,  neither  is  there  any  fluid  secreted,  nor  any  trace  of  a 
newly-formed  false  membrane.  The  orifices  of  the  glandular  tubes,  which 
are  much  more  visible  than  in  the  unimpregnated  condition,  are  alone  seen 
upon  the  surface. 

For  a  short  time  after  it  has  entered  the  womb,  the  ovule  is  free  from  all 
adhesions,  but  soon  becomes  permanently  fixed  at  the  point  where  it  was 
arrested  at  the  outset.  Before  studying  the  means  by  which  at  a  later  period 
it  becomes  adherent  to  a  circumscribed  portion  of  the  uterine  parietes,  let 
us  examine  the  facts,  and  sec  what  can  be  learned  respecting  the  youngest 
ovules  which  it  has  been  possible  to  observe  up  to  the  present  moment. 

In  the  beautiful  Atlas  of  M.  Coste,  is  figured  and  described  the  uterus  of 
a  young  primiparous  woman,  who  committed  suicide  about  the  twentieth  or 
twenty-first  day  of  her  pregnancy,  and  whose  body  was  opened  at  the  Morgue 


172  PREGNANCY. 

of  Paris.  The  size  of  the  organ  was  nearly  double  that  of  the  normal  con- 
dition. A  longitudinal  incision  was  made  through  its  posterior  wall,  after 
which  it  was  opened  and  spread  out,  so  as  to  exhibit  the  whole  extent  of  the 
cavity.  The  latter  was  free  as  in  the  unimpregnated  condition,  and  con- 
tained no  fluid.  The  mucous  membrane  was,  however,  much  thickened  and 
tumefied,  presented  numerous  irregular  folds,  and  was  furnished  throughout 
with  a  rich  network  of  vessels.  Notwithstanding  the  general  hypertrophy 
of  the  mucous  membrane,  a  sort  of  soft  tumor  was  discoverable,  situated  on 
the  anterior  surface  of  the  uterus  between  the  two  Fallopian  tubes,  as 
though  the  membrane  were  thicker  there  than  elsewhere.  (See  Plate  III, 
Fig.  1.)  Upon  incising  this  elevated  portion,  the  ovum  was  recognized  by 
the  villi  of  its  chorion.  The  internal  orifices  of  the  tubes  and  of  the  neck 
were  free  and  permeable  as  usual. 

Another  woman  was  examined  at  the  Morgue,  who  had  committed  suicide 
about  the  fortieth  day  of  her  pregnancy.  The  uterus,  which  was  much  larger 
than  in  the  preceding  case,  was  incised  longitudinally  on  its  anterior  surface, 
and  so  disposed  as  to  exhibit  the  greatest  possible  extent  of  the  internal 
imrface. 

As  in  the  foregoing  specimen,  the  mucous  membrane,  which  was  very  vas- 
cular throughout  and  greatly  hypertrophied,  was  in  some  points  still  more 
puffed  up,  and  furrowed  with  folds  and  wrinkles. 

The  upper  two-thirds  of  the  cavity  were  occupied  by  a  soft,  fluctuating 
tumor,  situated  upon  the  posterior  surface  between  the  two  Fallopian  tubes. 
Externally,  this  tumor  presented  altogether  the  appearance  and  organiza- 
tion of  the  mucous  membrane  lining  the  remainder  of  the  womb.  The 
lower  third  of  the  cavity  was  free,  so  that  the  cavity  of  the  neck  could  be 
entered  without  any  obstacle  presenting.  The  openings  of  the  tubes  were 
also  permeable.  An  incision  upon  the  most  prominent  part  of  the  tumor 
revealed  a  cavity  inclosing  an  ovum. 

The  most  superficial  examination  of  these  two  pieces  convinced  us :  1. 
That  the  internal  surface  of  the  uterus  is  lined  by  a  thick,  soft  membrane, 
which  presents  numerous  wrinkles  and  folds  at  several  points.  2.  That  the 
ovum  was  situated  in  the  upper  part  of  the  womb,  and  apparently  lodged 
in  a  cavity  perfectly  distinct  from  that  of  the  remainder  of  the  organ. 

Now,  in  order  to  solve  the  problem  which  we  are  investigating,  we  shall 
have  to  ascertain,  first,  the  nature  of  the  membrane  which  lines  the  cavity 
of  the  uterus,  as  also  of  those  forming  the  walls  of  the  pouch  which  in- 
closes the  ovule. 

The  decidua  with  its  three  parts,  (parietal,  ovular,  and  intermediate,)  is 
simply  the  mucous  membrane  in  a  state  of  hypertrophy.  1.  When  a  preg- 
nant uterus  is  compared  with  the  description  given  (page  95)  of  the  changes 
which  the  organ  undergoes  at  the  menstrual  period,  it  will  be  readily  per- 
ceived that  the  internal  layers  of  the  uterus  present  in  both  cases  the  same 
physical  properties,  the  former  being,  however,  more  tumefied,  vascular, 
and  folded.  It  will  also  be  seen,  especially  after  the  uterus  has  been  im- 
mersed in  spirits  and  water,  that  the  numerous  small  openings  are  merely 
the  glandular  apertures  enlarged,  which  are  observable  upon  the  mucous 
membrane  in  the  unimpregnated  condition  (page  80).     Finally,  the  demon- 


OF    THE    DECIDUA  I  TZ 

stration  is  completed  by  the  researches  of  M.  Robin,  showing  thai  this 
membrane,  like  that  of  the  unimpregnated  uterus,  is  composed  of  the  same 
anatomical  elements,  that  is  to  say:  1,  of  embryo-plastic  elements;  2, 
of  laminated  fibres,  both  in  the  embryonic  state  or  that  of  fibrd-plastic 
bodies,  and  in  that  of  fully  developed  filaments ;  3,  of  special  cells ;  4,  of 
an  amorphous  matter ;  5,  of  glands ;  6,  of  vessels ;  7,  that  it  is  covered 
with  cylinder-epithelium  becoming  tessellated  during  gestation.  All  these 
elements  are,  to  be  sure,  in  a  hypertrophied  and  changed  condition,  but 
inasmuch  as  M.  Robin  has  followed  their  changes  step  by  step,  there  can 
be  no  doubt  as  to  their  identity. 

2.  The  ovum  is  inclosed  in  a  distinct  cavity,  separated  from  that  of  the 
uterus  by  a  membranous  partition,  which  has  to  be  incised  in  order  to  ex- 
pose it.  This  is  the  membrane  hitherto  described  as  the  decidxia  reflexa  ; 
now  what  is  it?  It  presents,  throughout,  the  characters  of  the  uterine 
mucous  membrane ;  it  has  the  same  physiognomy,  the  same  arrangement, 
the  same  vascularity,  and  the  same  glandular  orifices ;  only  there  is  upon 
its  most  prominent  portion  a  small  circular  space,  around  which  the  vessels 
disappear.  This  space,  which  is  whiter,  or  of  a  lighter  rose  color  than  the 
remainder,  is  the  largest  in  the  most  advanced  ovum.  The  membrane  is 
distinctly  continuous  with  the  uterine  mucous  membrane  at  its  base,  and 
the  vessels  traversing  it  are  absolutely  the  same  with  those  which  ramify 
in  the  latter.  Finally,  microscopic  investigations  leave  no  doubt  that  the 
structure  of  the  two  membranes  is  identical.  With  the  same  physical 
qualities,  continuity  of  tissue,  and  identity  of  structure,  the  membrane 
surrounding  the  ovum,  the  decidua  reflexa  of  authors,  can  be  nothing  else 
than  a  portion  of  the  mucous  membrane  of  the  uterus. 

3.  If  the  ovum  be  removed  from  the  cavity  which  inclosed  it,  the  bottom 
of  the  latter  is  found  to  be  lined  by  a  membrane  which  is  thickly  sown 
with  anfractuosities  or  irregular  lacuna?  of  various  sizes,  in  which  those 
villi  of  the  chorion  were  engaged  which  subsequently  form  the  placenta. 
It  is  the  portion  of  the  mucous  membrane  to  which  the  fecundated  ovule 
adhered  at  the  outset,  and  is  consequently  continuous  with  that  covering 
the  parietes,  and  identical  in  regard  to  structure. 

Therefore,  the  ovule,  which  upon  entering  the  womb  lies  free  in  the 
cavity,  becomes,  after  the  lapse  of  a  period  as  yet  unascertained,  enveloped 
by  and  lodged  in  a  sort  of  fold  of  the  mucous  membrane. 

The  manner  in  which  this  inclusion  of  the  ovule  is  effected  is  a  subject  of 
hypothesis ;  for,  although  the  ovule  has  been  observed  when  free,  at  the 
outset,  as  also  when  completely  enveloped  after  the  third  week  of  gesta- 
tion, observations  are  wanting  for  the  intermediate  period.  Therefore,  in 
the  absence  of  direct  information,  we  give  the  explanation  proposed  by  M. 
Coste,  and,  indeed,  it  is  difficult  to  conceive  how  the  phenomenon  could  take 
place  otherwise. 

After  traversing  the  Fallopian  tube,  the  ovum  escapes  from  its  internal 
orifice,  and  falls  into  the  cavity  of  the  uterus.  On  account  of  the  swelling 
of  the  mucous  membrane,  this  cavity  is  almost  obliterated,  and  the  ovule 
is  consequently  supported  between  two  opposite  points  of  the  hypertrophied 
and    softened    membrane,     Therefore,    it    rarely' progresses   very  far,   and 


174  PREGNANCY. 

usually  becomes  fixed  upon  the  fundus  near  the  middle  of  the  interval 
between  the  orifices  of  the  two  tubes. 

Now,  notwithstanding  its  minuteness,  it  is  impossible  that  the  ovum 
should  not  depress  the  softened  tissue  with  which  it  is  in  contact,  and  it 
soon  excavates,  so  to  speak,  a  cell  in  their  substance. 

As  the  ovule  increases  in  size,  the  swelling  of  the  mucous  membrane  also 
progresses,  especially  at  the  point  where  the  former  is  arrested.  As  a  con- 
sequence of  this  simultaneous  development,  the  depression  produced  by  tho 
ovule  in  the  substance  of  the  mucous  membrane  becomes  deeper,  and  it  is 
gradually  buried,  first  one-quarter  of  it,  then  one-half,  until  at  last  it  is 
almost  completely  hidden  and  inclosed.  (Richard,  Extract  from  the  Les- 
sons of  M.  Coste.)  In  proportion  as  it  becomes  more  deeply  buried,  the 
edges  of  the  cavity  excavated  by  it  seem  to  grow  up  around  it,  at  first  to 
the  level  of  the  most  projecting  portion,  and  then  approach  each  other,  so 
as  gradually  to  contract  the  opening  by  which  a  communication  is  main- 
tained with  the  remainder  of  the  uterine  cavity.  The  borders  of  the 
opening  draw  still  nearer,  and  finally  circumscribe  a  minute  orifice,  the 
trace  of  which  remains  for  a  short  time  only  in  the  form  of  a  central  de- 
pression or  umbilicus.  The  umbilicus  itself  at  last  disappears,  and  from 
this  time  the  ovum  is  completely  imprisoned  in  a  sort  of  cyst,  whose  walls 
are  composed  exclusively  of  the  mucous  membrane. 

Whatever  may  be  thought  of  this  theory,  we  find  in  the  uterus,  five  or 
six  weeks  after  conception,  an  entirely  free  space,  the  ovum  occupying  but 
a  portion  of  the  cavity,  and  a  greatly  hypertrophied  mucous  membrane, 
which  at  the  point  where  the  ovum  is  fixed,  seems  to  fold  upon  itself  in 
order  to  embrace  the  latter.  We  have  now  to  ascertain  what  becomes  of 
the  uterine  mucous  membrane  during  gestation,  as  also  of  the  two  layers 
produced  by  its  folding. 

EXPLANATION  OF   PLATE   IL 

Fio.  1.  Uterus  at  the  twentieth  or  twenty-fifth  day  of  gestation.  Half  the  natural 
aj*e. 

e,  c    Mucous  membrane  of  the  uterus,  with  its  rich  vascularization. 

c/.   The  portion  of  mucous  membrane  which  covers  the  ovum. 

x.  The  small  circular  space  around  which  the  vessels  disappear,  and  whose  centre 
presents  the  appearance  of  a  recently  closed  umbilicus. 

u,  u  Muscular  structure  of  the  uterus,  exhibiting,  upon  the  cut  surface,  a  multitude 
of  venous  sinuses  in  various  degrees  of  development. 

m,  m.  Muscular  portion  of  the  neck,  distinguished  from  that  of  the  body  by  the 
absence  of  venous  sinuses. 

I.  Vaginal  portion  of  the  neck. 

V.  A  gland  of  Naboth,  greatly  distended. 

q,  q.  The  ovaries.  On  the  one  to  the  right  is  a  highly  developed  corpus  luteum.  g; 
its  surface  is  very  vascular,  and  on  its  apex  is  perceived,  g',  the  cicatrix  of  the  opening 
through  which  the  ovule  escaped. 

t,  t.  Fallopian  tubes. 

/>,  p.   Fimbriated  extremities  of  the  tubes.       , 

FlG.  2.  Is  the  same  specimen  as  the  preceding,  except  that  a  circular  incision  has 
oeen  made  in  the  porticn  of  mucous  membrane  upon  which  the  ovum  is  situated,  and 
the  flap  turned  back,  so  as  to  exhibit  its  deep  or  ovular  surface. 


V 


m- 


ks 


s. 


V    :i     A  : 


JPiglll 


^  f  * . 


OF   THE    DECTDUA.  175 

fi.  Section  of  the  mucous  membrane  covering  the  ovum,  exhibiting  its  thickness  rela- 
tively to  that  which  lines  the  remaining  portion  of  the  womb. 

c".  Internal  surface  of  the  flap  of  the  uterine  mucous  membrane  (decidua  reflexa) 
which  covered  the  ovum. 

at.  The  ovum,  with  its  surface  thickly  set  with  short  but  considerably  branched 
villi,  which  come  into  direct  contact  with  the  maternal  blood. 

Fia.  3.  The  uterine  mucous  membrane  of  the  specimen  represented  by  Fig.  ], 
dinded  on  a  level  with  the  neck,  and  seen  separately.  The  blood  which  distended  its 
vessels  having  escaped,  in  consequence  of  its  immersion  in  spirits  and  water,  the 
vascular  network  which  it  exhibited  has  disappeared,  and  permits  us  to  see  that  its 
entire  surface  is  perforated  with  minute  openings,  which  are  the  glandular  apparatus, 
observable  upon  the  mucous  membrane  of  the  uterus  in  the  unimpregnated  condition. 
The  portion  of  mucous  membrane  beneath  which  the  ovum  was  situated,  is  incised  as 
in  the  preceding  figure,  but  the  ovum  is  here  removed,  so  as  to  exhibit  completely  the 
walls  of  the  cavity  which  contained  it. 

/.  The  cell  or  cavity  which  contained  the  ovum,  strewn  with  anfractuosities  and 
irregular  lacuna?,  in  which  the  villi  of  the  chorion  were  inserted. 

c" '.  Internal  surface  of  the  flap  of  mucous  membrane  which  covered  the  ovum.  The 
same  lacuna?  are  observable  in  it  as  on  the  opposite  surface,/,  but  they  are  smaller, 
less  numerous,  and  less  pronounced. 

«.  Sections  of  the  venous  sinuses  of  the  mucous  membrane  of  the  uterus. 

tf,  t'.  Internal  orifice  of  the  Fallopian  tubes,  rendered  visible  in  the  preparation  by 
the  greater  unfolding  of  the  mucous  membrane.  There  is  no  indication  of  their  ever 
having  been  obliterated. 

Description  of  the  Three  Portions  of  the  Decidua.  —  From  the  foregoing 
account,  it  appears  that  the  different  portions  of  the  decidua  are  the  result 
of  the  successive  phases  of  development  of  the  uterine  mucous  membrane, 
and  in  order  to  follow  with  greater  ease  the  metamorphosis  of  the  latter,  we 
shall  describe  consecutively  the  three  portions  of  the  decidua. 

A.  The  Intermediate  or  Utero-epichorial  Membrane.  —  If,  after  the  removal 
of  the  ovum,  the  cavity  which  it  occupied  be  examined  during  the  first 
month,  or  the  first  half  of  the  second,  a  multitude  of  irregular  grooves  or 
lacunae,  of  variable  size  and  depth,  in  which  the  villi  of  the  chorion  were 
engaged  (see  PI.  III.,  Fig.  3),  will  be  perceived  upon  the  mucous  membrane 
which  forms  its  bottom.  These  lacuna?,  into  which  smaller  ones  enter,  and 
which  are  so  numerous  as  to  give  to  this  portion  of  the  membrane,  the 
appearance  of  an  areolar,  erectile  tissue,  are  supposed  by  M.  Coste  to  be 
produced  by  the  wearing  away,  or  corrosion  of  the  vessels,  which  are  more 
hypertrophied  at  this  point  than  elsewhere,  by  the  invading  growth  of  the 
chorion ;  so  that  the  lacuna?,  by  communicating  directly  in  this  way  with 
the  subjacent  uterine  sinuses,  permit  the  maternal  blood  to  flow  into  the 
cavity  occupied  by  the  ovum,  and  come  into  direct  contact  with  the  villi 
of  the  chorion. 

The  presence  of  the  ovum  determines  at  this  point  a  considerable  hyper- 
trophy of  all  the  elements  of  the  mucous  membrane.  The  corresponding 
villi  of  the  chorion  also  become  greatly  developed,  and  all  together  con- 
stitute at  a  rather  later  period  the  mass  of  the  placenta.     (See  Placenta.) 

B.  The  ovular  decidua  or  epichorial  membrane  presents  very  different 
appearances  according  to  the  period  at  which  it  is  examined.  Shortly 
after  its  formation  is  completed,  that  is  to  say,  after  the  umbilicus  is 
obliterated,  it  differ?  in  no  respect  from  the  parietal  mucous  membrane:  its 


176  PREGNANCY. 

uterine  surface  has  the  same  color,  the  same  thickness,  the  same  profile* 
supply  of  vessels,  and  is  perforated  in  like  manner  with  numerous  glandular 
orifices.  Its  ovular  surface  presents  at  the  same  period  irregular  cavities 
or  lacunae  of  variable  depth,  resembling  precisely  those  described  as  belong- 
ing to  the  inter-utero-placental  layer,  and  which  are  penetrated  in  like 
manner  by  the  villi  of  the  portion  of  the  chorion  covering  the  ovum.  (See 
PI.  III.,  Figs.  2  and  3.)  But  as  the  ovum  enlarges,  it  elevates  and  extends 
it,  until  about  the  end  of  the  first  month,  when  commencing  atrophy  is 
observed  at  its  centre,  in  consequence  of  which  its  vessels  and  glands  dis- 
appear, and  the  whole  of  this  portion  of  the  membrane  gradually  loses  its 
thickness.  (See  PI.  III.,  Fig.  1.)  The  result  is,  that,  either  in  consequence 
of  the  distention  which  it  undergoes,  or  of  the  pressure  exerted  upon  its 
most  prominent  portion  through  the  growth  of  the  ovum,  a  small  but 
gradually  enlarging  circular  space,  deprived  of  vessels,  appears  in  its  centre, 
whilst  the  remainder  of  the  surface  presents  the  same  vascularity  as  the 
parietal  mucous  membrane.  This  central  portion  becomes  very  thin,  even 
at  periods  when  the  circumference  of  the  membrane  preserves  a  considerable 
thickness. 

The  obliteration  of  the  vessels  and  the  atrophy  of  the  glandules  progress 
from  the  centre  towards  the  circumference,  so  that  by  the  third  month  the 
epichorial  membrane  differs  so  materially  from  the  parietal  mucous  mem- 
brane that,  except  at  the  parts  adjacent  to  the  points  where  the  two  become 
continuous,  the  glandular  orifices  and  vessels  are  no  longer  discoverable. - 

The  lacuna?  described  as  existing  upon  the  ovular  surface,  are  still  further 
effaced  by  the  atrophy,  and  as  the  villi  of  the  chorion,  which  were  inserted 
into  them,  can  no  longer  derive  thence  the  means  of  nutrition,  they  become 
useless  and  atrophied  in  like  manner. 

As  the  development  of  the  ovum  progresses,  it  tends  naturally  to  encroach 
upon  the  cavity  of  the  womb,  and  consequently  to  bring  the  epichorion  and 
the  uterine  mucous  membrane  nearer  together,  until,  at  the  end  of  the  third 
month,  the  two  are  in  contact.  At  a  rather  later  period,  they  become  so 
adherent  as  to  be  separated  with  difficulty. 

It  is  hardly  necessary  to  state,  that  when  thus  deprived  of  its  vascular 
elements,  the  ovular  portion  of  the  membrane  can  no  longer  accommodate 
itself  to  the  distention  produced  by  the  ovum,  otherwise  than  by  a  progres- 
sive thinning  of  the  membrane,  and  that  its  extreme  delicacy  in  advanced 
ovums,  or  at  maturity,  is  to  be  thus  accounted  for.  It  is  found,  however, 
even  after  labor,  adhering  either  to  the  chorion  or  to  the  parietal  mucoua 
membrane. 

c.  The  uterine  or  parietal  decidua  retains  the  characters  already  described 
until  towards  the  end  of  the  second  month  ;  but  from  this  time  it  begins  to 
grow  thinner,  and  its  numerous  and  deep  folds  are  gradually  effaced.  This 
first  period  of  degeneration  progresses,  however,  very  slowly,  for  at  the  third 
month,  the  state  of  the  membrane  is  very  nearly  the  same  as  at  the  meD- 
etrual  periods.    (Richard.    Thesis.) 

[  TuLTi-t Iii-r  uiili  this  atrophy  begins  also  a  transformation  of  the  epithelium, 
which  gradually  passes  from  the  cylindric  to  the  tessellated  form.  There  is  no 
proof,    however,   thai    the    prismatic    cells    assume    directly   t he    pavimentous    form; 


OF     THE     DECIDUA.  177 

indeed  Robin  says  that,  on  the  contrary,  some  time  after  fecundation  takes  place, 
the  epithelium  of  the  cavity  of  the  body  of  the  uterus  exfoliates,  as  it  were,  cell  by 
cell,  or  at  the  most  by  little  shreds,  and  is  replaced  by  the  pavimentous  form. 

This  metamorphosis  of  the  epithelium  is  true  for  both  the  uterine  and  ovular 
decidua,  and  when  the  two  come  in  contact,  we  have,  as  a  result  of  their  adher- 
ence, a  layer  of  epithelial  cells  in  the  very  substance  of  the  membrane.  So  inti- 
mate, indeed,  is  the  adhesion  between  the  so-called  uterine  and  reflected  portions 
of  the  decidua,  that  at  the  time  of  delivery  they  seem  to  form  but  a  single  layer.] 

From  the  fourth  month,  the  uterine  decidua  begins  to  lose  the  marks  of 
energetic  vitality  which  had  characterized  it  hitherto,  and  its  external 
appearance  (perforation  and  vascularity)  is  altered;  it  becomes  atrophied 
to  such  an  extent  as  to  be  reduced  by  the  seventh  month  to  the  one-twenty- 
fifth  of  an  inch  in  thickness,  and  is  still  thinner  at  the  termination  of  preg- 
nancy. Though  inseparable  at  the  outset  from  the  subjacent  tissue,  it  is 
now,  in  a  measure,  an  independent  membrane,  and  may  be  isolated  and  de- 
tached in  strips  of  considerable  size.  This  ready  separation  is  due,  accord- 
ing to  M.  Robin,  to  the  commencing  development,  near  the  end  of  the  fourth 
month,  between  it  and  the  muscular  tissue  of  a  new  membrane,  which  is  at 
first  soft,  downy,  and  homogeneous,  the  first  trace,  in  fact,  of  the  mucous 
membrane  which  is  to  replace  the  decidua  that  falls  after  labor.  It  thickens 
gradually  during  the  latter  half  of  gestation,  and  lines  the  internal  surface 
of  the  uterus,  whose  muscular  fibres  are  not  therefore  left  exposed  by  the 
•complete  decollation  and  expulsion  of  the  uterine  decidua,  which  takes 
place  after  labor. 

[Of  the  Decidua  at  the  end  of  Gestation. — At  the  end  of  gestation  the  decidua 
is  thin,  and  of  a  grayish  or  rose-colored  appearance  ;  it  has  an  areolar  texture,  and 
an  irregular  surface.  The  outermost  of  its  two  surfaces  is  throughout  in  relation 
with  the  internal  walls  of  the  uterus,  now  covered  by  the  first  elements  of  the 
newly  forming  mucous  membrane.  Its  internal  surface  adheres  closely  to  the 
chorion,  and  at  the  point  of  insertion  of  the  placenta  becomes  involved  in  the  struc- 
ture of  the  uterine  surface  of  that  organ.    (See  Placenta.) 

When  the  after-birth  is  delivered,  a  rupture  takes  place  be;  veen  the  mucous  mem- 
brane of  the  body  of  the  uterus  and  that  of  the  neck.  The  Matter  remains,  whilst 
that  of  the  body,  now  the  decidua,  is  expelled  with  the  ovuji,  of  which  it  forms 
the  exterior  envelope. 

It  is  soft  and  easily  torn  ;  and  although  the  vessels  which  traversed  it  whilst  it 
adhered  to  the  uterus,  are  for  the  most  part  obliterated  and  atrophied,  some  of  them 
may  yet  be  found  full  of  blood.  By  scraping  with  the  nail,  it  may  be  removed  in 
little  shreds.  Its  softness  and  opacity  serve  to  distinguish  it  from  the  other  envel- 
opes of  the  ovum,  which  are  stronger  and  transparent. 

The  inter-utero-placental  mucous  membrane  is  duplicated,  so  to  speak,  by  bein£ 
separated  into  two  layers:  the  thinner  is  removed  with  the  placenta,  into  the  forma- 
tion of  which  it  enters  (maternal  placenta,  see  Placenta)  ;  the  thicker  remains 
adherent  to  the  uterus,  and  is  soon  blended  with  the  newly  formed  mucous  mem- 
brane of  the  adjacent  parts.  The  inter-utero-placental  mucous  membrane  does  not, 
therefore,  entirely  fall  away;  no  newly  formed  mucous  membrane  is  to  be  found 
beneath  it,  so  that  it  cannot  be  properly  called  a  decidua. 

If,  therefore,  we  consider  the  whole  uterine  mucous  membrane  at  the  time  of 

delivery,  we  find  that  the  portion  lining  the  neck  is  not  detached,  and  that  the 

greater  part  of  the  inter-utero-placental   portion  remains  adherent  and  assists  iD 

the  formation  of  the  new  membrane.      (See  Phenomena  appertaining  to  the  lying-ii- 

12 


178  PREGNANCY. 

state.)  The  parietal  and  ovular  mucous  membrane  constitutes  the  only  portion  which 
is  wholly  expelled  and  which  really  deserves  the  name  of  Decidua.] 

From  the  details  into  which  we  have  entered,  it  is  evident: 

1.  That,  excepting  the  membranes  proper  of  the  ovum,  the  amnion  and 
c1io"ion,  the  uterus  contains  none  other  than  its  own  mucous  membrane. 

2.  That  at  the  moment  when  the  ovule  enters  the  cavity  of  the  uterus, 
this  membrane  has  throughout  a  thickness  equal  to,  if  not  greater  than, 
that  which  it  possesses  at  the  menstrual  period. 

3.  That  this  abnormal  thickness  is  wholly  due  to  the  hypertrophy  of  its 
constituent  elements,  and  especially  of  peculiar  cells,  as  proved  by  M. 
Robin. 

4.  That  immediately  after  the  arrival  of  the  ovule,  the  vitality  of  the 
uterus  seems  to  be  concentrated,  in  a  great  measure,  at  that  point  of  the 
mucous  membrane  where  the  ovule  is  arrested. 

5.  That,  as  a  consequence  of  this  concentration  of  the  vital  forces,  the 
point  mentioned  of  the  mucous  membrane  becomes  thickened,  grows  up 
around  the  ovule,  investing  it  with  a  circular  ring,  which  soon  incloses  it 
completely. 

6.  That  from  this  moment  the  ovule  is  separated  from  the  uterine  tissue 
by  the  intermediate  mucous  membrane,  and  from  the  remainder  of  the  uterine 
cavity  by  the  ovular  mucous  membrane. 

7.  That,  after  the  first  month,  the  ovular  mucous  membrane  becomes 
atrophied  from  the  centre  towards  the  circumference,  loses  its  vascularity 
and  glandular  openings. 

8.  That  this  atrophy  involves  that  of  the  corresponding  villi  of  the 
chorion,  whilst  those  which  are  in  relation  with  the  intermediate  mucous 
membrane  become,  like  the  latter,  considerably  developed,  and  subsequently 
form  the  placenta. 

9.  That,  from  the  fourth  month,  the  parietal  mucous  membrane  begins 
to  degenerate,  growing  gradually  thinner,  in  consequence  of  the  diminution 
of  its  tissue,  and  of  the  obliteration  by  atrophy  of  its  vessels  and  glands. 

10.  Finally,  that  a  new  mucous  membrane  is  formed  by  which  the  old 
one  is  removed  farther  and  farther  from  the  muscular  tissue  to  which  it 
adhered  so  closely  at  the  outset,  and  that  after  labor  it  is  completely 
detached  and  expelled  with  the  ovum. 

This  exfoliation  of  the  mucous  membrane  of  the  uterus  after  parturition 
is  explained,  to  a  certain  extent,  by  the  formation  of  a  new  mucous  mem- 
brane ;  but  it  is  much  more  difficult  to  understand  how  it  should  occur  in 
abortions  during  the  early  months,  when  the  adhesion  between  the  mucous 
and  muscular  tissues  is  so  very  firm.  It  is  true,  that  the  exfoliated  decidua 
i<  much  thinner  than  that  which  may  be  observed  still  adhering  to  the 
uterus  at  the  same  period,  and  that  we  may  suppose  a  part  only  of  the  pari 
etal  membrane  to  have  been  detached. 


DEVELOPMENT  OP  THE  HUMAN  OVUM.  179 

CHAPTER  IV. 

OP  THE   HUMAN   OVUM   AFTER   FECUNDATION 

The  human  ovule,  prior  to  fecundation  and  at  its  full  matuiity,  is  com- 
posed, as  previously  stated  (page  90):  1st.  Of  the  vitelline  membrane,  or  the 
envelope.  2d.  Of  a  granular  liquid  contained  in  this  membrane,  and 
called  the  vitellus  (yolk).  3d.  Of  a  little  vesicle  inclosed  in  the  first,  and 
situated  in  the  midst  of  the  granular  liquid.  This  is  the  germinal  vesicle, 
originally  discovered  by  Purkinje,  in  the  eggs  of  birds,  and  subsequently 
proved  by  M.  Coste  to  exist  in  those  of  mammalia.  4th,  and  lastly.  Of 
the  germinal  or  proligerous  spot  (macula  germinativa),  which  is  detached 
from  the  clear  contents  of  the  germinal  vesicle,  and  is  held  in  suspension 
in  the  fluid  which  the  latter  contains. 

If  the  ovule  be  examined  several  weeks  after  the  fecundation  has  taken 
place,  it  will  be  found  to  have  undergone  some  very  remarkable  transfor- 
mations; for  it  is  then  composed  of  such  different  parts,  that  if  comparative 
anatomy  had  not  furnished  us  opportunities  of  observing,  step  by  step,  and 
hour  by  hour,  the  divers  modifications  it  passes  through  before  the  organi- 
zation is  fully  completed,  we  would  not  believe  it  to  be  one  and  the  same 
product.  Thus,  at  the  end  of  the  second  or  third  week  after  fecundation, 
it  exhibits  some  very  different  elements  to  the  observer:  for  example,  we 
encounter,  in  passing  from  without  inwards  :  1st.  The  chorion,  a  thick  exterior 
membrane,  studded  with  numerous  villosities.  2d.  A  much  thinner  mem- 
brane, situated  more  internally,  and  designated  as  the  amnios.  3d.  A  more 
or  less  considerable  space  between  these  two  envelopes,  that  is  filled  by  an 
albuminous  liquid,  in  the  midst  of  which  a  little  vesicle  (the  umbilical 
vesicle)  is  situated.  And  4th.  A  liquid  fills  the  cavity  of  the  amnios,  the 
quantity  varying  with  the  period  of  pregnancy,  and  in  this  fluid  is  the  embryo. 

Finally,  let  us  add  that  the  ovule  is  enveloped  nearly  throughout  by  a 
double  membrane,  which  at  first  is  entirely  foreign  to,  but  subsequently 
contracts  intimate  relations  with  it ;  this  is  the  deciduous  membrane.  But 
before  studying  the  constituent  parts  of  the  ovum  at  an  advanced  period 
of  its  development,  let  us  see  what  is  their  proper  commencement,  and 
how  they  can  arise  out  of  the  simple  elements  that  form  the  ovule  prior 
to  conception. 

When  the  ovule  has  attained  its  full  maturity,  the  vesicle  in  which  it  is 
inclosed  becomes  the  seat  of  an  excitation  which  determines  there  a  con- 
siderable afflux  of  fluid,  and  causes  its  progressive  distention.  This  hyper- 
trophy may,  as  we  have  seen,  be  either  spontaneous,  or  produced  by  coition 
or  other  venereal  excitement.  As  a  consequence  of  the  distention,  the 
vessels  on  that  portion  of  the  vesicle  which  projects  the  farthest  from  the 
surface  of  the  ovary  become  atrophied,  its  walls  grow  thinner,  and  soon 
give  way,  thereby  permitting  the  ovule  to  escape,  which,  in  passing  out, 
draws  along  with  it  a  part  of  its  granular  cumulus.  The  ovum  then  en- 
gages in  the  tube,  whose  enlarged  extremity  had  been  applied  to  the  ovary. 
It  must  not  be  supposed  that  the  period  for  the  ovule's  arrival  in  the  tube 
is  invariable  in  the  same  species  of  animals,  and  it  probably  varies  in  the 
human  rare  also,  though  nothing  positive  is  known  on  that  point.     Pending 


180  PREGNANCY. 

its  stay  in  the  ovary,  tlie  ovum  underwent  no  appreciable  modification . 
but  as  soon  as  it  enters  the  oviduct,  the  beginning  of  those  changes  it  must 
necessarily  pass  through,  in  order  to  give  birth  to  a  new  being,  is  observed  ; 
and  hence,  to  study  these  modifications  in  due  course,  we  must  first  examine 
those  manifested  in  the  tube,  and  then  such  as  do  not  appear  until  after  its 
arrival  in  the  uterine  cavity. 

ARTICLE   I. 

CHANGES  OF  THE  OVUM  IN  THE  TUBE. 

It  has  heretofore  been  always  impossible  to  study  these  changes  in  the 
nunian  ovum,  and  the  description  we  are  about  to  give  is  the  result  of 
observations  made  on  the  ova  of  mammalia,  especially  of  the  dog  and 
rabbit ;  but  analogy  favors  the  belief  that  similar  phenomena  take  place 
in  the  human  species ;  indeed,  the  strongest  resemblance  exists  between  the 
ovum  of  the  latter,  and  the  unfecundated  ovum  of  a  bitch ;  besides,  the 
youngest  ova  that  have  been  studied  in  the  female,  exactly  resemble  those 
which  have  arrived  at  a  certain  degree  of  development  in  animals.  It  is, 
therefore,  extremely  probable  that  if  they  are  endowed  with  the  same 
organization  before  conception,  and  still  exhibit  a  perfect  resemblance  after 
the  fecundation,  they  must  have  passed  through  similar  successive  transforma- 
tions. From  analogy  as  well  as  observation,  it  is  supposed  that  in  the  human 
female  ten  or  twelve  days  are  occupied  in  the  passage  of  the  ovum  through 
the  tube. 

[Disappearance  of  the  Germinal  Vesicle.  —  By  the  time  the  ovum  has  reached  the 
oviduct,  it  has  become  impossible  to  find  in  it  either  vesicle  or  germinal  spot;  and 
this  disappearance  of  the  vesicle  and  of  the  collection  of  granules  at  its  centre,  con- 
stitutes the  first  change  perceptible  in  the  ovum  subsequent  to  its  departure  from 
the  ovary. 

The  disappearance  shows  that  the  ovum  is  mature,  but  occurs  independently  of 
fecundation. 

Condensation  of  the  Vitellns.  —  During  the  early  part  of  its  passage  through  tho 
tu^e,  the  vitellus  becomes  more  dense  (Bischoff)  and  compact,  in  consequence  of 
which  it  no  longer  fills  the  vitelline  membrane,  but  leaves  an  intervening  space 
occupied  by  a  clear  and  transparent  fluid.  So  great  is  this  condensation,  that  if  its 
envelope  be  opened,  the  vitellus  is  found  to  be  a  solid  body,  capable  of  division  by 
means  of  a  very  fine  needle  into  two,  four,  and  six  portions.     (See  Bischoff* s  Atlas.) 

Appearance  of  Polar  Globules.  —  Succeeding  the  disappearance  of  the  germinal 
vesicle  and  during  the  condensation  of  the  vitellus,  there  is  formed  on  the  surface 
of  the  latter  a  transparent  globule,  5Jff  of  an  inch  in  diameter,  to  which  the  name 
polar  globule  has  been  given.  From  the  point  of  its  formation  and  during  the  time 
of  its  appearance,  there  is  a  retrocession  of  the  granules  of  the  vitellus  and  conse- 
quent separation  from  the  hyaline  and  transparent  substance  which  united  them. 
It  would  thus  seem  that  the  polar  globule  is  produced  by  a  sort  of  exudation  or 
accumulation  of  the  hyaline  substance  of  the  vitellus,  and  the  point  at  which  it  is 
formed  indicates  where  will  take  place  the  first  furrow  of  segmentation,  and  where 
at  a  later  period  the  cephalic  extremity  of  the  embryo  will  make  its  appearance. 

Within  a  few  minutes  after  it  is  first  perceived,  the  polar  globule  constitutes  a 
hemispherical  projection  on  the  surface  of  the  vitellus,  and  finally  separates  from, 
and  remains  simply  contiguous  to  it. 

In  some  species  of  animals,  two,  three,  or  four  polar  globules  are  thus  suc- 
cessively produced,  all  taking  their  origin  from  the  same  point.  When  the  last  of 
them  is  formed,  all  unite  to  form  a  single  one,  which  soon  exhibits  distinctly  an 
investing  membrane  and  a  cavity. 


DEVELOPMENT    OF    THE     HUMAN     OVUM. 


181 


The  polar  globule  thus  produced  remains  beneath  the  vitelline  membrane  and 
unconnected  with  the  phenomena  which  are  to  take  place  in  its  vicinity.  I» 
becomes  useless,  in  fact,  as  soon  as  formed,  leing  intended  only  to  prepare  the 
way  for  the  segmentation  of  the  vitellus,  which  we  are  soon  to  study. 

Whethtr  fecundation  has  occurred  or  not,  the  germinal  vesicle  disappears,  the 
vitelluf  condenses,  and  the  polar  globules  form;  but  the  changes  which  we  are 
next  to  study  take  place  only  in  fecundated  ova.     (Memoirs  of  Prof.  Ch.  Robin.) 

Formation  of  the  Vitelline  Nucleus  and  Segmentation  of  the  Vitellus.  —  Both  the 
layer  of  albumen  which  surrounds  the  fecundat-ed  ovum,  and  the  vitelline  mem- 
brane become  thicker  during  the  passage  through  the  second  half  and  internal  third 
of  the  Fallopian  tube;  but  the  most  remarkable  changes  take  place  in  the  vitellus 
(Harry,  Bischoff,  Robin). 

Whilst  the  vitellus  is  undergoing  its  condensation,  a  clear  spot  appears  in  its 
centre  and  increases  so  rapidly  in  size  by  crowding  aside  the  vitelline  globules, 
that  in  about  one  hour  it  has  attained  a  diameter  of  from  ■$£,  of  an  inch  to  the  -x\^ 
of  an  inch  (Robin).  The  spot  is  called  the  vitelline  nucleus,  and  has  nothing  in 
common  with  either  the  germinal  vesicle  or  the  polar  globule.  It  is  composed  of  a 
thick  fluid  without  a  cavity  or  distinct  walls. 

The  vitelline  nucleus  has  barely  attained  the  above-mentioned  diameters  before 
it  is  seen  to  become  elongated  and  constricted  near  the  middle,  and  finally  separates 
into  two  halves.  This  separation  is  the  signal  for  the  segmentation  of  the  vitellus 
which  itself  divides  into  two  halves,  in  the  centres  of  which  are  found  the  corre- 
sponding halves  of  the  vitelline  nucleus. 

Fig.  52.  Fig.  53. 


a.  The  layer  of  albumen,     v.  The  vitelline  membrane. 

.Each  half  of  the  vitellus  divides  in  its  turn  into  two  parts  and  so  successively, 
until  by  the  process  of  subdivision  the  entire  vitellus 
(which  at  first  presented  two  regularly  rounded  por-  Fia-  54- 

tions  (Fig.  52),  then  four  (Fig.  53),  and  then  eight, 

&c,  the  vitelline  spheres  becoming  more  numerous  A  T 

and    smaller)  acquires    the    appearance  of  a  mul-         / 
berry;  whence  is  derived  the  name  muriform  body  ,  •.   :  •      ;  S 

(Fig.  54)  applied  to  the  vitellus  after  the  segmenta-     , 
tion  is  completed. 

The  segmentation  of  the  vitellus  would  seem  to  (_';;,• 

be  dependent  upon  the  segmentation  of  the  vitelline      \ 

nucleus,  a  portion  of  which   is  found  in   the  centre  / 

of  each  vitelline  sphere.] 

The  time  necessary  for  the  ovum  to  traverse 
the  tube  is  very  variable  in  differenl  animals, 
and  oven  sometimes  in  the  same  species;  thus, 
according  to  M.  Coste,  i  be  ovum  of*  rabbits  does 

not   reach   the   uterus  before  the   third   or  the 
fourth    day,  whilst    in   the  bitch,   it    has   been      n,;l„,. 


The  Fecundated  ovum  at  a  more 

advanced  stage. 

*..  The  albuminous  layer  surrounding 

the  vitelline  membrane  v,  which    is 

seen  t"  !»•  thickened  and  to  contain 

withiu   its  cavity    the   mulberry-like 


182 


PREGNANCY. 


found  in  the  tubes  as  late  as  the  tenth,  twelfth,  or  even  fifteenth  day ;  and 
we  have  formerly  stated  that,  in  the  human  species,  no  one  case  has  ever 
proved  its  existence  in  the  womb  prior  to  the  twelfth  day.  However,  it  is 
well  to  remark,  that,  as  a  general  rule,  the  passage  is  very  rapid  through 
the  external  half  of  the  tube,  whilst  its  progress  through  the  second  half 
and  especially  through  the  last  third  is  exceedingly  slow,  in  consequence 
perhaps  of  the  extreme  narrowness  of  this  portion  of  it. 

Finally,  the  ovum  augments  somewhat  in  volume  during  its  course,  being 
probably  nourished  at  first  at  the  expense  of  the  granulations  which  accom- 
pany it,  and  subsequently  by  absorbing  the  albuminous  liquid  secreted  in 
the  oviduct  itself.1 

ARTICLE   II. 

MODIFICATIONS   OF   THE   OVULE    FROM    ITS    FIRST   ARRIVAL   IN   THE   WOMB 
UNTIL   AFTER   THE   DEVELOPMENT    OF   THE   ALLANTOIS. 

[Formation  of  the  Blastodermic  Membrane.  —  At  the  time  of  its  entrance  into  the 
cavity  of  the  uterus,  the  ovum  is,  therefore,  composed  of  the  muriform  body,  the 
thickened  vitelline  membrane,  and  a  thin  layer  of  albumen  surrounding  the  latter. 
Each  little  sphere  of  the  muriform  body  now  undergoes  an  internal  change  by 
which  its  outer  portion  is  transformed  into  a  membrane,  so  that  each  segmentary 
sphere  represents  a  cell  with  a  homogeneous  envelope  and  granular  tissue.  Shortly 
after  this,  fluid  collects  in  the  centre  of  the  muriform  body  and  presses  to  the  cir- 
cumference the  spheres  or  cells  of  which  the  body  had  been  composed.  In  con- 
sequence of  this  pressure  the  cells  become  flattened  and  applied  to  the  vitelline 
membrane  so  as  to  form  a  sort  of  lining  thereto,  and  by  their  mutual  adherence 
form  a  second  membrane  enclosed  within  the  primary  one.] 

This  second  membrane  is  not  easily  recognized ;  but  if  the  example  of 
M.  Coste  be  followed,  and  the  ovule  be  placed  in  water,  it  will  become  quite 
apparent.     In  fact,  a  very  curious  endosmotic  phenomenon  then  takes  place ; 
the  water  passing  through  the  vitelline  membrane 
detaches  the  second  vesicle  in  such  a  manner  that 
the   latter,    being    completely   isolated,   as   also 
puckered    and    corrugated    in   every   direction, 
floats   or   hangs    suspended   in    the   new   liquid 
which  distends  the  vitelline  membrane ;  and  to 
this  M.  Coste  has  given  the  title  of  the  blasto- 
dermic membrane.     But  while  this  blastodermic 
vesicle,  or  membrane,  is   being   developed,  the 
layer  of  albumen  which  surrounds  the  ovum  on 
its  first  arrival  in  the  uterus,  disappears  and  con- 
Tbe  ovule  shortly  after  its  arrival     sequently  the  vitelline  vesicle  loses  much  of  its 

in  the  womb,    k.  The  diminished  ?  .  J 

albuminous  layer,    v.  The  vitelline      thlCkneSS. 

membrane,    b.  The  blastodermic         Hitherto,  the  ovum   still   remained  free   and 
without  any  adhesion  to  the  uterine  walls ;  but 


Fig.  55. 


membrane. 


1  This  layer  of  albumen  which  surrounds  the  ovum  of  the  rabbit  and  of  the  roebuck, 
whilst  it  remains  in  the  tube,  does  not  exist  around  the  ovum  of  the  bitch  and  of  the 
sow.  On  account  of  these  differences,  it  will  remain  uncertain  whether  it  envelops 
the  human  ovum  until  observations  which,  as  yet,  it  has  been  impossible  to  make, 
shi»U  settle  the  question. 


DEVELOPMENT    OF    THE    HUMAN    OVUM. 


183 


it  commences  about  this  period  to  contract  more  intimate  relations  with  the 
latter,  and  hence  can  no  longer  be  displaced  by  blowing  upon  it.  At  the 
same  period  a  rounded,  whitish  spot  begins  to  appear  on  some  pi  int  of  the 
blastodermic  vesicle,  which  seems  to  be  detached,  or  to  stand  in  relief;  this 
has  been  called  the  tache  embryonnaire  Uhe  embryonic  spot)  by  M.  Coste, 
and  it,  like  the  blastodermic  vesicle,  is  composed  of  cellular  granulations, 
excepting  that  these  latter  are  more  contracted,  and  are  aggregated  in  a 
larger  quantity  at  this  point.     (Figs.  56  and  57.)     At  the  same  time,  a 


Fig.  57. 


Fig.  56.  The  blastoderm,  with  the  embryonic  spot  seen  in  front,  v.  Tho  vitelline  membiane.  e.  Th« 
external  layer  of  the  blastoderm,     f.  The  embryonic  spot. 

Fig.  57.  The  same  figure  in  profile,  to  show  the  two  layers  of  the  blastoderm.  V.  The  vitelline  membrane. 
E.  The  external;  and  I,  the  internal  or  intestinal  layer  of  the  blastoderm. 

minute  examination  is  all  that  is  necessary  to  convince  us  that  the  vesicle, 
as  also  the  embryonic  spot,  is  composed  of  two  laniinse,  lying  in  contact 
with  each  other,  but  which  may  be  separated  by  a  couple  of  fine  needles. 
To  render  this  doubling  of  the  blastoderm  more  evident,  we  present  two 
theoretical  figures,  exhibiting  it  at  the  same  stage  of  development.  In  the 
first  (Fig.  56),  which  is  a  front  view  of  the  ovum,  the  blastoderm  with  the 
rounded  embryonic  spot  is  seen.  The  same  figure,  in  profile  (Fig.  57), 
shows  the  two  blastodermic  lamina?,  both  presenting  a  swelling  near  the 
embryonic  spot.  One  has  been  called  the  external,  serous,  or  animal  layer, 
and  the  other  is  denominated  the  internal,  mucous,  or  the  vegetative  one. 
Shortly  after  this  period,  the  embryonic  spot  enlarges  by  the  further  addi- 
tion of  granules,  but  more  in  one  of  its  diameters  than  in  the  others,  so  as 
to  exchange  its  rounded  for  an  elongated  form. 

A  considerable  projection  above  the  external  face  of  the  blastoderm  may 
be  simultaneously  noticed,  which  exhibits  a  convexity  towards  the  vitelline 
membrane  and  a  concavity  looking  to  the  central  part  of  the  ovum  (Fig. 
58)  ;  and  thenceforth  the  cavity  of  the  blastodermic  vesicle  is  divided  into 
two  distinct  portions,  the  one  embryonic,  the  other,  which  is  the  larger, 
foiming  the  umbilical  vesicle. 

A  line  of  greater  obscurity  may  soon  be  recognized  at  the  centre  of  this 
spot,  being  the  first  trace  of  the  embryo.  The  margins  of  this  spot  fold 
inwards,  as  do  also  the  extremities,  thereby  giving  rise  to  an  elongated 
body  curved  like  a  boat  with  the  ends  swollen,  in  consequence  of  their 
doubling  up,  and  a  cavity  of  some  depth  at  its  centre.  The  body  of  the 
embryo  is  then  readily  distinguished. 

The  extremity  that  is  most  swollen  is  called  the  cephalic,  and  the  other, 
or  less  voluminous  one,  the  caudal  extremity;  about  that  time  the  serous 


184 


PREGNANCY 


Fio.  58. 


A  section  of  a  more  devel- 
oped ovum,  in  which  the  two 
portions,  the  embryonic  and 
the  umbilical  vesicle,  begin  to 
appear,  o.  The  umbilical  ves- 
icle. I.  The  internal  layer  of 
the  blastoderm,  e.  The  exter- 
nal layer,  v.  The  vitelline 
membrane. 


laniime  of  the  blastoderm  can  be  traced  as  continuous  with  the  nicst  ex- 
ternal layers  of  the  embryonic  body,  whilst  the  mucous  one  forms  its 
internal  plane.  In  }  roportion  as  the  embryonic  spol 
loses  its  distinctive  characters,  numerous  little  eleva- 
tions, irregularly  scattered  over  the  external  surface 
of  the  ovum,  are  seen  to  develop  themselves,  being, 
in  fact,  the  commencement  of  those  villosities  which 
subsequently  stud  the  exterior  surface  of  the  chorion. 
During  the  progress  of  these  phenomena,  the  ex- 
ternal, or  serous  layer  of  the  blastoderm  (Fig.  59) 
forms  a  fold  around  the  part  which  has  been  trans- 
formed into  the  embryo,  and  curved  as  already  stated  ; 
the  fold  of  the  serous  layer  being  especially  so  at 
the  caudal  and  cephalic  extremities.  The  fold  grad- 
ually enlarges  above,  below,  and  on  the  sides,  in  such 
a  manner  as  to  form  a  true  hood  over  the  head  and 
caudal  termination;  hence  named  from  this  resem- 
blance the  cephalic  and  caudal  hoods.  These  folds 
elongate  rapidly  (Fig.  60',  passing  along  the  dorsal 
regions  of  the  embryo,  and  ultimately  coming  into 
contact  on  the  median  line,  unite  so  as  to  form  a  pouch  surrounding  the 
embryo,  and  continuous  with  it  along  the  whole  circumference  of  its  large 

ventral  opening.     Although  at  first  almost   in 
Fl0-59-  direct  contact  with  the  embryo,  it  is  soon  after 

separated  from  it  by  a  certain  quantity  of 
liquid,  becoming  its  immediate  envelope,  and 
receiving  the  name  of  the  amnion,  and  the  in- 
terposed fluid,  that  of  the  amniotic  liquor. 

As  to   the  external  layer  of  the  fold,  it  is 
manifestly  continuous  with  the  serous  lamina 
of  the  blastoderm,  and  although  primarily  ap- 
plied to  the  preceding,  it  is  speedily  separated 
therefrom  by  the  interposition  of  a  liquid  which 
removes   them  farther  and    farther  from  each 
other,  until  at  last  its  exterior  face  is  brought 
into  contact  with  the  vitelline  vesicle.     Accord 
ing  to  some   authors,    these   two   become   con- 
founded, and  by  uniting  form  the  outer  mem- 
brane of  the  ovum  ;  but  others  teach  that  the 
vitelline  vesicle  will  be  gradually  absorbed  (as 
we  have  endeavored  to  represent  in  the  plates  Figs.  61,  62,  and  63),  while 
the  external  lamina  of  the  blastoderm  is  being  developed,  and  the  latter 
alone  will  then  constitute  the  enveloping  membrane. 

At  the  point  of  junction,  the  cephalic  and  caudal  hoods  constitute,  by 
their  union,  a  kind  of  membranous  bridge,  which  there  joins  the  amnios  to 
tho  chorion.  This  bridge  is  gradually  absorbed,  and  the  two  membranes 
become  completely  isolated.     (See  Fiizs.  *>1  and  Uii.  < 

Such  is  the  view  most  generally  received  on   the  mode  of  formation  of 


A  section  showing  the  origin  and 
rirst  traces  of  the  amnios,  o.  The 
umbilical  vesicle.  I.  The  intestinal; 
and  i .  the  external  layer  of  the  blas- 
toderm, v.  The  vitelline  membrane. 
C  c.  Origin  of  the  cephalic  and  cau- 
dal amniotic  hoods. 


DEVELOPMENT    OF    THE     HUMAN    OVUM. 


18fi 


Fio.  60. 


The  amniotic  hoods  more  developed. 
0.  The  umbilical  vesicle,  i.  The  internal 
or  intestinal ;  and  E,  the  external  layer  ol 


c.  The  limit  of  the  am- 

The  vitelline  membrane. 


the  amnios.  We  must  mention,  however,  one  other,  which,  without  being 
new,  has  latterly  acquired  considerable  importance  by  the  discussions  which 
it  has  created  at  the  Academy  of  Sciences. 

We  have  just  seen  that  the  amnios  is  directly 
continuous  at  the  umbilicus  with  the  abdom- 
inal walls  of  the  embryo,  which  is  in  fact  so 
manifest,  that  no  just  ground  of  belief  is 
afforded  that  the  latter  was  ever  independent 
of  the  amnios,  as  some  have  recently  supposed. 
Messrs.  Oken,  Pockels,  Serres,  and  Brescliet 
have  endeavored,  notwithstanding,  to  prove 
that  the  amnios  once  existed  as  an  independent 
vesicle,  distended  by  a  fluid  ;  and  that  after- 
wards the  foetus,  by  coming  into  contact  with 
it,  caused  its  depression,  and  became  envel- 
oped by  it,  like  a  double  night-cap,  but  having 
no  other  relation  with  it  than  that  of  simple 

apposition;  or,  in  other  words,  that  the  amnios   the  blastoderm,   i  \  a  portion  of  tne  ex 
had  the  same  connection  with  the  embryo  as   E»."rhe Xibryo 
the  serous  membranes  with  the  viscera  they   niotic  hoods,  v. 
cover. 

Messrs.  Coste,  Velpeau,  and  Bischoff  have  combated  this  view  success- 
fully, in  my  estimation,  by  contending  for  the  existence,  at  all  periods,  of 
the  continuity  we  have  just  described,  and 
they  cannot  possibly  admit  an  opinion  which 
is  founded  solely  on  pathological  alterations. 
For  my  own  part,  after  examining  the 
preparations  of  M.  Coste,  I  can  have  no 
doubt  as  to  the  little  value  of  such  asser- 
tions. 

Immediately  after  the  amnios  is  formed, 
the  margins  of  the  embryonic  spot,  and 
especially  its  true  extremities,  become  more 
and  more  turned  inwards,  thereby  aug- 
menting the  concavity  which  it  previously 
exhibited  ;  and  at  the  bottom  of  the  groove 
thus  constituted,  the  mucous  lamina  of  the 
blastoderm  is  observed  to  concur  in  forming 
the  intestinal  canal,  which  is  represented  at 
this  early  period  by  an  elongated  gutter, 
communicating  freely  with  the  interior 
cavity  of  the  blastoderm.  But,  in  propor- 
tion as  this  constantly  increasing  inversion 
of  the  lateral  walls,  and  of  the  extremities 
of  the  embryo,  progresses,  this  communication  becomes  more  and  more 
contracted,  «o  that  in  a  short  time  the  intestinal  cavity  only  connects  with 
the  blastodermic  vesicle  by  a  contracted  pedicle;  and  thenceforth,  this 
latter  receives  the  name  of  the  umbilical  vesicle,  and  the  vessels  which  arf 


Fio.  01. 


This  figure  shows  the  amnios  ;:linot.  ^viu- 
pleted,  and  likewise  the  origin  of  tl  ■>  all  an 
tols.  o.  The  umbilical  vesicle,  i.  The  in 
testinea.  e.  The  amnios,  k'.  The  externa 
layer  of  the  blastoderm,  or  the  non-vascular 

chorion,  v.  The  vitelline  membrane,  o.  The 
amniotic  hoods  ready  to  close  up.  a.  The 
alluutois. 


186 


PREGNANCY. 


Fio.  62. 


distributed  to  its  vascular  layer,  consisting  of  two  veins  that  enter,  and  an 
artery  that  emerges  from  the  embryo,  are  called  the  omphalo-mesentcric  ves- 
sels.    (Fig.  61.) 

As  the  contraction  of  the  ventral  opening  in  the  embryo,  and  the  circum- 
scription of  the  umbilical  vesicle  go  on,  we  may  observe  at  the  inferior 
part  of  the  intestinal  canal,  just  in  the  region  where  the  bladder  and  rectum, 
during  the  earlier  days  of  embryonic  life,  are  confounded  under  the  name 
>f  cloaca;  we  observe,  I  repeat,  the  intestinal  parietes  to  form  there  a  slight 

elevation.  Now,  this  little  tumor  (Fig. 
61)  gradually  elongates,  so  as  to  con- 
stitute a  minute  vesicle,  which  commu- 
nicates by  its  narrow  pedicle  with  the 
intestinal  cavity ;  this  is  the  allantois, 
which  has  been  known  for  a  long  time 
to  exist  in  mammalia,  but  which  M. 
Coste  was  one  of  the  first  to  detect  in 
the  human  ovum.  The  allantois  is 
scarcely  formed  before  it  is  provided 
both  with  venous  and  arterial  vessels, 
consisting  of  the  two  umbilical  arteries, 
and  one  umbilical  vein ;  the  former 
arising  from  the  primitive  iliacs,  the 
latter  going  to  the  liver,  as  may  be  seen 
somewhat  later. 

This  little  vesicle  passes  through  the 
umbilicus  at  first  alongside  of  the  pedi- 
cle belonging  to  the  umbilical  vesicle, 
and  soon  undergoes  a  rapid  develop- 
ment. The  growth  of  the  allantois  and 
its  vessels  is  so  rapid  that  it  soon  comes 
into  contact  with  the  external  membrane 
of  the  ovum.  In  some  animals,  the 
allantois  comes  into  juxtaposition  by 
its  base  with  only  one  point  of  the  chorion,  and  becomes  attached  there  ; 
and  then  the  terminal  extremities  of  the  umbilical  vessels  not  only  reach 
this  membrane,  but  even  extend  for  the  most  part  to  the  villosities  devel- 
oped on  its  external  surface,  and  acquire  there  a  considerable  growth. 

In  others  (see  Figs.  62  and  63),  the  allantois  spreads  out  like  an  umbrella 
around  the  embryo  and  umbilical  vesicle,  and  supplies  itself  to  the  whole 
external  face  of  the  amnios,  as  well  as  to  the  internal  one  of  the  chorion,  then 
the  two  laminae  are  fused  into  each  other  in  such  a  way  as  to  leave  no  trace 
of  the  allantois.     (Figs.  62  and  63.) 

The  development  of  the  allantois  completes  the  essential  part  of  the 
ovum,  although  by  reference  to  Fig.  55,  Plate  IV.,  it  will  now  be  found  to 
consist:  1,  of  the  embryo;  2,  of  a  variable  quantity  of  liquid  in  which  it 
iwims ;  3,  of  the  amnios,  already  considerably  distended,  and  forming  a 
sheath  to  the  parts  that  pass  through  the  ventral  aperture ;  4,  of  the  umbil- 
ical vesicle  situated  between  the  amnios  and  chorion,  whose  delicate  pedicle, 


This  figure  shows  the  rapid  progress  of  the 
allantois,  and  how  it  spreads  over  the  foetus,  the 
umbilical  vesicle,  and  the  amnios.  This  latter 
begins  to  ensheathe  the  pedicle  of  the  umbilical 
vesicle  and  that  of  the  allantois  in  such  a  way 
as  to  form  a  commencement  of  the  cord.  The 
vitelline  membrane  disappears  more  and  more. 
o.  Tli.'  nr.ibilical  vesicle,  e'.  The  amnios,  e". 
The  external  layer  of  the  blastoderm,  c.  The 
point  where  the  two  hoods  come  into  contact. 
v.  The  vitelline  membrane  almost  entirely  atro- 
phied,   a.  The  allantois. 


DEVELOPMENT   OF   THE    HUMAN    OVUM. 


187 


Fio.  Co. 


with  the  oniphalo-mesenteric  vessels 
appertaining  to  it,  however,  still  com- 
municate with  the  intestinal  cavity ; 
5,  the  pedicle  of  the  allantois  vesicle 
still  charged  with  the  umbilical  ves- 
sels ;  6,  the  space  between  the  amnios 
and  chorion,  partly  occupied  by  the 
umbilical  vesicle,  but  principally 
filled  with  a  liquid  called  by  M.  Vel- 
peau  the  reticulated  or  the  vitriform 
body,  according  to  the  degree  of  its 
consistence;  and  7,  of  the  outer  en- 
velope, or  the  chorion. 

The  phenomena  yet  to  be  studied 
have  special  reference  to  the  enlarge- 
ment of  the  ovum,  and  the  develop- 
ment of  the  embrVO.  ^n  **"8  figure,  the  allantois  has  spread  over  ti  s 

whole  internal  surface  of  the  ovum,  and  but  verj 
slight  traces  are  left  of  the  continuity  between  tL« 
amnios  and  that  part  of  the  external  layer  of  th* 
blastoderm  which  formed  the  non-vascular  chorion  ■ 
the  amnios  incloses  the  umbilical  cord  more  and 
more.  o.  The  umbilical  vesicle,  e'.  The  amnio* 
c.  The  point  where  the  two  hoods  are  fused  into 
each  other,  and  form  but  a  single  membrane,  e". 
The  external  layer  of  the  blastoderm.  a.  The 
allantois.     v.  The  vitelline  membrane. 

ARTICLE  III. 

OF   THE   FCETAL   APPENDAGES. 

These  comprise  the  allantois,  the  umbilical  vesicle,  the  amnion,  and  the 
chorion. 

§  1.  Of  the  Allantoid  Vesicle. 

By  the  time  the  amnion  has  become  a  completely  closed  sac,  a  little 
pyriforra  vesicle,  which  we  have  denominated  the  allantois,  is  observed, 
about  the  tenth  day,  to  spring  from  the  inferior  part  of  the  intestinal  canal, 
and  taking  on  a  rapid  growth  soon  becomes  applied  by  its  base  to  the  in- 
ternal surface  of  the  chorion.  The  terminal  branches  of  the  two  umbilical 
arteries  and  vein,  as  previously  stated,  ramify  on  the  walls  of  this  vesicle  ; 
and  hence  the  urachus,  which  is  nothing  else  than  the  pedicle  of  the  allan- 
tois, is  accompanied  in  its  course  by  three  blood-vessels  (see  Fig.  3,  Plate 
IV.),  two  of  which  (i  i)  are  arterial,  coming  from  the  iliacs,  and  called  the 
umbilical  arteries.  They  run  to  the  chorion,  where  they  ramify,  and  ulti- 
mately reach  the  villi  that  form  the  foetal  placenta.  The  third  trunk  is 
venous,  and  is  known  as  the  umbilical  vein. 

The  umbilical  vein  j  leaves  the  right  auricle  of  the  heart  at  the  point  /, 
and  soon  after  receives  the  contents  of  the  vena  cava  inferior  k;  it  then 
traverses  the  under  surface  of  the  liver  m,  to  which  it  sends  a  copious  vas- 
cular supply,  and,  before  passing  this  organ,  receives  the  omphalo-meseuteric 
vein  at  the  point  o;  then,  after  leaving  the  liver,  it  gains  the  left  sidf 
of  the  abdomen  between  the  walls  of  this  cavity  and  the  intestinal  fold  E 


183  PREGNANCY. 

next,  by  turning  abruptly  towards  the  umbilical  cord,  it  gets  to  the  left 
side  of  the  urachus,  and  accompanies  the  latter  to  the  chorion,  wheie  it 
follows  the  umbilical  arteries  into  the  villosities. 

After  the  earliest  periods  of  development  are  over,  there  is  but  a  single 
umbilical  vein  left,  although  during  the  first  part  of  the  embryonic  exist- 
ence two  are  met  with,  one  upon  each  side  of  the  urachus  (and  consequently 
one  for  each  umbilical  artery).  That  on  the  right  side  becomes  efface  1, 
but  its  traces  may  still  be  found  at  the  thirtieth  or  even  the  fortieth  day ; 
indeed,  some  such  existed  and  were  perceptible  on  the  embryo  I  am  now 
describing. 

When  the  umbilical  vein  has  actually  passed  the  liver,  it  gives  off  no 
branches  whatever,  in  its  course  along  the  urachus,  nor  does  it  divide  and 
subdivide  until  it  reaches  the  chorion.  But,  in  the  earlier  periods  of  ges- 
tation, when  the  two  exist,  they  are  observed  to  spread  over  the  walls  of 
the  chest  and  abdomen  in  the  form  of  a  large  vascular  plexus,  extending 
as  far  as  the  vertebral  column ;  however,  this  new  apparatus  soon  vanishes 
and  leaves  no  vestige  of  its  former  existence. 

The  body  of  the  allantoid  vesicle  disappears  very  rapidly,  and  scarcely 
a  trace  of  it  can  possibly  be  found  after  the  lapse  of  a  few  days  from  its 
first  appearance.  In  fact,  nothing  more  is  seen  than  a  cord  of  variable 
length,  extending  from  the  embryo  to  the  chorion,  and  having  the  umbilical 
vessels  inclosed  within  it.  This  likewise  becomes  gradually  atrophied  in 
such  a  way  as  to  disappear  altogether  in  the  substance  of  the  umbilical 
cord ;  nevertheless,  a  portion  of  it  still  persists  in  the  abdominal  cavity  of 
the  embryo,  forming  there  the  cord  subsequently  known  as  the  urachus  ; 
and  just  as  this  latter  terminates  in  the  rectum,  it  exhibits  a  small  swelling 
which  is  afterwards  converted  into  the  urinary  bladder.  We  may  remark, 
in  anticipation,  that  this  rudimentary  bladder  communicates  with  the 
rectum,  and  constitutes  there  that  transitory  cloaca,  whose  existence  in 
the  human  species  may  be  positively  verined  by  direct  observation.  It  is 
this  early  disappearance  of  the  allautois  which  has  induced  some  ovologists 
to  doubt  its  existence  in  the  human  race.  It  is  exclusively  destined  to 
bring  the  embryonic  vessels  into  contact  with  the  external  membrane  of 
the  ovum,  whence  they  are  soon  placed  in  their  proper  relation  with  the 
internal  surface  of  the  womb. 

§  2.  Of  the  Umbilical  Vesicle. 

This  vesicle  is  formed  exclusively  by  the  internal  or  mucous  layer  of  the 
blastoderm  ;  at  first,  it  is  very  voluminous,  occupying  nearly  the  whole 
cavity  of  the  ovum,  and  communicating  so  freely  with  the  intestinal  cavity 
as  to  form  with  it  apparently  but  a  single  vesicle.  But  the  gradual  con- 
traction of  the  ventral  opening  serves  to  separate  the  two,  as  we  have  already 
demonstrated,  leaving  only  a  pedicle  of  variable  thickness,  according  to  the 
3ize  of  this  aperture. 

Ihe  umbilical  vesicle  contains  a  yellowish-wl.ite  liquid  often  of  a  vitel- 
line yellowness,  in  which  numerous  granules  and  fat  globules  are  seen 
floating.  It  seems  to  be  formed  of  two  laminae,  between  which  the  vessels 
are  distributed  (see  Robin,  Journal  de  Physlologie,  1861).     As  the  amnion 


DEVELOPMENT  OF  THE  HUMAN  OVUM.  189 

becomes  developed,  the  vesicle  is  crowded  by  this  membrane,  and  is  then 
found  placed  between  the  external  face  of  the  latter  and  the  internal  sur- 
face of  the  chorion. 

In  consequence  of  the  development  of  the  allantois,  the  umbilical  vesicle 
loses  much  of  its  importance  in  the  human  species,  as  it  so  soon  becomes 
an  organ  of  little  value  either  to  the  growth  of  the  ovum  or  the  embryo : 
and  furthermore,  it  dwindles  away  speedily  ;  thus,  during  the  first  three 
weeks,  it  is  as  large  as  an  ordinary  pea,  but  after  the  fourt%  it  begins  to 
collapse  and  diminish  in  size,  and  at  six  weeks  subsequent  to  the  concep- 
tion, it  does  not  exceed  a  coriander-seed  in  bulk  ;  then  it  remains  stationary 
for  a  time,  not  disappearing  altogether  until  towards  the  fourth  month.  I 
have  observed  it  several  times  of  later  years  on  ova  of  three  to  three  and 
a  half  months,  in  which  it  generally  still  retained  the  volume  and  shape 
of  a  small  lentil,  being  of  a  yellowish  color,  and  having  its  surface  wrinkled. 
However,  I  may  remark,  that  its  size  appeared  very  variable  in  several  ova 
of  the  same  age. 

In  proportion  as  the  umbilical  vesicle  becomes  atrophied,  it  is  removed 
farther  and  farther  from  the  trunk  of  the  embryo,  in  consequence  of  the 
development  of  the  amnion,  and  its  pedicle  is  also  elongated  in  a  marked 
manner  ;  thus,  the  latter  is  from  two  to  six  lines  in  length,  being  continuous 
at  one  end  with  the  intestine,  and  at  the  other  with  the  vesicle  by  a  kind 
of  an  infundibuliform  expansion.  The  pedicle  is  apparently  separated  into 
two  portions  by  the  amnios,  before  the  abdominal  walls  are  completely 
closed  up ;  one  part  lying  between  the  spine,  or  rather  the  intestine,  and 
the  spot  afterwards  occupied  by  the  umbilicus,  while  the  other  remains 
exterior  to  the  abdomen.  This  pedicle  is  traversed  by  a  small  canal  for  the 
first  five  or  six  weeks  of  its  existence,  and  through  it  the  fluid  in  the  vesicle 
may  be  pressed  back  into  the  intestine,  but  it  is  obliterated  after  that  period. 
About  the  same  time,  also,  it  becomes  more  and  more  delicate,  and  ofter 
ruptures  from  its  great  elongation  ;  and  its  umbilical  portion  being  lost  in 
the  cord,  can  no  longer  be  traced  into  the  abdomen.  When  broken,  the 
vesicle  may  be  found  more  or  less  removed  from  the  root  of  the  cord,  and 
lying  between  the  chorion  and  amnion. 

The  umbilical  vesicle  has  a  rich  vascular  apparatus,  the  blood  of  which 
is  carried  to  and  from  the  embryo  by  the  intervention  of  two  trunks,  one 
venous,  the  other  arterial ;  both,  however,  accompany  the  pedicle,  and  form 
a  constituent  part  of  it.  The  first,  n  (see  Fig.  3,  PI.  IV.),  called  the  omphalo- 
mesenteric vein,  enters  the  abdomen,  winds  around  the  duodenum,  and  then 
opens  into  the  umbilical  vein  at  the  point  o,  just  as  the  latter  is  emerging 
from  the  liver.  As  it  passes  the  duodenum,  branches  are  given  off  to  the 
stomach  and  intestines,  and  when  it  discharges  into  the  umbilical  vein,  it 
sends  a  voluminous  trunk  to  the  liver.  That  portion  which  furnishes  the 
branches  just  described,  persists  in  the  adult  under  the  name  of  the  ventral 
or  hepatic-portal  vein,  whilst  all  the  rest  will  disappear  with  the  umbilical 
vesicle  and  its  pedicle. 

The  arterial  trunk  p,  accompanying  the  pedicle,  has  been  designated  as 
the  omphalo-mesenteric  artery.  Arising  from  the  aorta,  it  gains  the  summit 
of  the  intestinal  convolution,  and  gives  off  branches  to  the  mesentery  and 


190  PREGNANCY. 

to  the  intestine  itself;  then  it  reaches  the  pedicle,  and  follows  the  latter  to 
the  umbilical  vesicle,  upon  which  it  ultimately  ramifies.  The  part  that 
supplies  the  mesentery  is  converted  in  the  adult  into  a  mesenteric  artery, 
all  the  rest  being  effaced.  From  all  which,  it  appears  that  the  vascular 
system  of  the  umbilical  vesicle  represents  the  primitive  circulation  in  the 
embryo,  corresponding  in  it  to  the  sanguiferous  apparatus  of  the  yolk  of 
fowls.  Of  course,  these  vessels  will  become  atrophied  with  the  organ  to 
which  they  belong. 

The  umbilical  vesicle  seems  to  be  intended  to  serve  as  a  reservoir  for  the 
fluid  designed  to  nourish  the  foetus  during  the  first  weeks  of  intra-uterine 
existence. 

§  3.  Of  toe  Amnion. 

The  most  internal  membrane  of  the  ovum,  or  the  amnion,  is  formed  by 
the  inner  lamina  of  the  fold.,  or  the  cephalic  and  caudal  hoods  which  con- 
stituted the  external  serous  layer  of  the  blastoderm  surrounding  the  embryo. 
Being  continuous,  as  we  have  shown,  with  the  margins  of  the  ventral  open- 
ing, it  seems  at  first  to  be  attached  by  its  middle  part  to  the  skin  on  the 
dorsal  region. 

The  internal  amniotic  surface  subsequently  exhales  a  liquid  into  its  cavity, 
in  which  the  embryo  swims  freely;  hence  the  amnios  constitutes  a  little  sac 
around  the  foetus,  having  smooth  and  transparent  walls.  Its  inner  surface 
is  bathed  by  the  liquid  inclosed  in  the  cavity,  whilst  its  external  one  in 
separated  from  the  chorion  by  a  space  of  variable  size,  which  is  likewise 
filled  with  a  fluid  and  the  expansion  of  the  allantoid  vesicle. 

Originally,  this  membrane  was  not  concentric  with  the  chorion ;  but  in 
proportion  as  the  development  advances  it  presses  back  the  exterior  liquid 
and  the  allantoid  vesicle  more  and  more,  thereby  condensing  it,  and  finally 
comes  in  contact  with  the  external  envelope  of  the  ovum.  Now,  since  it 
adheres  to  the  periphery  of  the  umbilical  opening,  it  must  furnish,  by  such 
an  extension,  a  sort  of  membranous  sheath  to  the  pedicles  of  the  allantoid 
and  the  umbilical  vesicles,  as  well  as  to  their  accompanying  vessels,  sur- 
rounding them  throughout  their  course  from  the  umbilicus  to  the  chorion; 
and  all  the  parts  thus  inclosed  constitute  what  is  called  the  umbilical  cord; 
whence  it  follows  that  the  abdominal  cavity  itself  must  be  in  connection 
with  the  canal  represented  by  this  cord,  and  consequently  that  the  foetal 
appendages  may  communicate  with  it  through  the  route  thus  opened  to 
them.  It  is  thus  that  the  pedicle  of  the  umbilical  vesicle  becomes  united 
to  the  ileo-coecal  fold  of  intestine,  whilst  the  allantois  connects  with  the 
rectum  by  the  intervention  of  the  urachus. 

As  we  have  just  stated,  the  amnios  is  separated  from  the  chorion  during 
the  earlier  weeks  by  a  filled  space,  which  space  is  larger  in  proportion  a? 
the  ivum  is  the  more  recent.  This  extra-amniotic  liquid  forms  a  gelatinous 
or  albuminous  mass,  of  a  weblike  arrangement,  and  having  the  umbilical 
vesicle  in  its  midst.  The  mass  becomes  more  and  more  compact  by  pressure 
of  the  amnion,  which  has  a  constant  tendency  to  approach  the  chorion,  thus 
acquiring  the  aspect  of  a  membrane  (the  membrana  media  of  BiscLoff ), 
which  is  situated  between  the  chorion  and  the  amnion,  where,  says  this 


DEVELOPMENT  OF  THE  HUMAN  OVUM.  191 

author,  it  may  be  readily  distinguished  towards  the  end  of  pregnancy,  as  a 
gelatinous,  though  continuous  membrane.  M.  Velpeau  gave  it  the  name 
of  the  vitriform  or  reticulated  body,  but  Robin  has  shown  its  structure  to  be 
identical  with  that  of  the  allantoid  vesicle.  Velpeau  was,  therefore,  correct 
in  regarding  the  reticulated  body  as  the  analogue  of  the  allantoid,  of  which 
it  is  really  but  the  remains. 

The  amnion  undergoes  no  important  change  during  the  ulterior  develop- 
ment of  the  ovum,  nor  does  its  texture.  Of  course,  it  would  be  more  firm 
and  consistent,  acquiring  by  time  a  greater  resemblance  to  the  serous  mem- 
branes, although  it  neither  incloses  nor  possesses  vessels  at  any  period. 
Nevertheless,  says  Duges,  it  probably  has  some  openings,  which  permit  the 
waters,  exhaled  by  the  uterine  capillaries,  and  received  by  the  vessels  of  the 
decidua  and  the  villi  of  the  chorion,  to  be  diffused  around  the  foetus ;  but 
this  perspiration  of  the  liquids  secreted  by  the  internal  uterine  surface,  may 
very  possibly  be  a  simple  phenomenon  of  endosmosis. 

§  4.  Waters  of  the  Amnion. 

The  amniotic  cavity  is  filled  with  a  liquid,  in  which  the  foetus  is  im- 
mersed. At  the  commencement  of  pregnancy,  this  fluid  is  of  slight  density, 
and  more  or  less  transparent  and  limpid,  but  towards  term  it  becomes  viscid, 
unctuous,  and  more  consistent  than  pure  water :  sometimes  it  is  as  clear  as 
serum  ;  at  others,  it  is  of  a  light  yellow  or  greenish  color.  It  frequently  be- 
comes lactescent,  turbid,  and  interspersed  with  yellowish-gray,  or  even  black 
albuminous  flakes  ;  again,  in  certain  cases,  it  is  strongly  tinged  with  yellow, 
when  the  membranes  are  ruptured,  from  the  admixture  of  a  quantity  of 
meconium  ;  it  exhales  a  disagreeable  odor,  analogous  to  that  of  the  sper- 
matic fluid,  and  its  taste  is  slightly  saline. 

The  quantity  of  the  amniotic  fluid  varies  greatly ;  thus,  in  the  early 
months  it  is,  relatively  to  the  foetus,  more  abundant,  in  proportion  as  the 
embryo  is  younger.  Riolan  found  four  ounces  in  an  ovum  containing  a 
foetus  of  the  size  of  an  ant.  The  weight  of  the  foetus  and  that  of  the  fluid 
at  the  middle  of  gestation,  are  very  nearly  equal.  Again,  dating  from  this 
period,  the  difference  is  generally  in  favor  of  the  foetus,  and  the  weight  of 
the  latter  at  term  is  four  or  five  times  greater  than  the  waters,  which  seldom 
exceed  a  pound  or  a  pound  and  a  quarter ;  consequently,  if  the  assertion  is 
true,  that  the  waters  augment  in  their  absolute  quantity  until  term,  it  is 
equally  so  to  say  they  increase  relatively  to  the  foetus  in  the  first,  and 
diminish  in  the  second  half  of  pregnancy.  In  fact,  the  variations  in  thir 
respect  are  infinite,  even  at  the  time  of  the  accouchement. 

According  to  the  analysis  of  Vauquelin,  100  parts  of  amniotic  liquor 
consist:  of  water  98*8;  of  albumen,  hydrochlorate  of  soda,  phosphate  of 
lime,  and  lime,  12.  The  interesting  question  now  arises:  What  is  the 
source  of  the  amniotic  fluid  ?  Some  assert  that  it  comes  from  the  mother  ; 
others,  that  it  is  produced  by  the  foetus.  Chaussier,  Meckel,  and  Beclard, 
adopting  an  intermediate  opinion,  suppose  that  its  secretion  takes  place 
simultaneously  from  the  female  and  her  product. 

Everything  proves,  says  M.  Velpeau,  that  the  liquor  amnii  is  the  result 
of  a  transudation  or  of  a  simple  exhalation,  like  the  serum  of  the  pleura. 


[92  PREGNANCY. 

pericardium,  &c,  and  that  this  process  requires  no  particular  canals  for  its 
accomplishment,  being  a  phenomenon  of  pure  vital  imbibition. 

According  to  Burdach,  the  amniotic  waters  cannot  be  secreted  by  the 
fietus,  because  they  exist  prior  to  its  formation,1  and  therefore  they  must  be 
exclusively  furnished  by  the  internal  uterine  surface,  and  reach  the  cavity 
of  the  amnios  by  traversing  its  walls.  We  also  believe,  that  the  greater 
part  of  this  liquid  comes  from  the  mother's  organs  ;  yet  we  must  add  that 
it  also  contains  certain  products,  secreted  by  the  foetus:  for  instance,  it  is 
frequently  colored  by  some  meconium,  and  besides,  it  is  almost  certain  that 
the  urine  may  be  discharged  into  the  amniotic  cavity  during  the  latter 
months  of  pregnancy.  A  few  incontestable  facts  prove  that  such  an  evacua- 
tion is  necessarv  to  the  maintenance  of  foetal  life:  thus,  Billard  and  T.  W. 
King  record  having  seen  cases  of  ruptured  bladder,  resulting  from  imper- 
foration  of  the  urethra ;  ami  further,  Desormeaux  and  P.  Dubois  have 
observed  an  obliteration  of  this  canal  in  two  stillborn  children,  which  had 
given  rise  to  an  enormous  distention  of  the  bladder,  ureters,  and  both  kid- 
neys ;  indeed,  the  latter  were  found  transformed  into  two  multilocular  cyst?. 
Similar  facts  have  been  presented  before  the  Academy  of  Medicine  by  MM. 
Depaul  and  Moreau. 

According  to  some  authors,  the  principal  use  of  these  waters  is  to  contri- 
bute to  the  nutrition  of  the  foetus,  during  at  least  a  great  part  of  gestation. 
(See  Nutrition  of  the  Foetus.)  However  this  may  be,  the  waters  of  the  am- 
nios serve  during  pregnancy  to  maintain  the  insulation  of  the  external  foetal 
parts  before  the  skin  becomes  covered  with  the  sebaceous  coat  hereafter  to 
be  described  ;  to  promote  the  active  movements  of  the  foetus  and  its  develop- 
ment, both  of  which  would  have  been  greatly  incommoded  without  this 
intervention,  by  the  pressure  of  the  uterine  walls ;  to  protect  the  foetus  from 
all  external  violence,  and  to  afford  it  the  means  of  conforming  to  the  laws 
of  gravity.  They  likewise  favor  a  uniform  expansion  of  the  womb,  and 
remove  all  pressure  from  the  umbilical  cord,  thus  assuring  the  integrity  of 
the  foeto-placental  circulation  both  during  pregnancy  and  labor.  In  the 
latter,  they  seem  destined  to  guard  the  child  from  the  violence  of  the  uterine 
contractions,  which,  without  them,  would  certainly  compromise  its  existence ; 
to  aid  in  forming  the  amniotic  bag,  the  engagement  of  which  renders  the 
dilatation  of  the  neck  more  uniform  and  easy  ;  to  lubricate  the  pelvic  canal, 
and  thus  facilitate  the  descent  of  the  foetus  ;  and  lastly,  they  render  manipu- 
lations of  every  kind  less  difficult  than  they  otherwise  would  be. 

§  5.  Of  the  Chorion. 

The  chorion  is  the  most  external  envelope  of  the  ovum.  Writers  are  by 
no  means  unanimous  in  their  views  as  to  the  elements  of  which  it  is  com- 
posed. Thus,  some  of  them,  as  we  have  had  occasion  to  state,  suppose  that 
it  is  formed  by  the  vitelline  membrane,  the  external  lamina  of  the  blasto- 
derm, and  the  allantoid  vesicle,  uniting  to  constitute  a  single  layer.  Accord- 
ing to  others,  on  the  contrary,  the  vitelline  membrane  will  disappear  soon 

1  It  is  only  necessary  to  recall  our  remarks  on  the  development  of  the  amnios  to 
refute  this  opinion. 


DEVELOPMENT   OF   THE    HUMAN    OVUM.  193 

after  the  doubling  of  the  blastodermic  vesicle,  and  the  external  lamina  of 
the  latter,  conjoined  with  the  allantois,  will  then  form  the  chorion. 

[M.  Robin's  view  of  the  subject  is  as  follows:  According  to  M.  Coste,  three 
kinds  of  chorion  appear  successively,  one  of  which,  however,  disappears  in  conse 
quence  of  the  development  of  its  successor  which  is  substituted  for  it.  Theirs* 
horion,  which  lasts  for  a  few  days  only,  is  formed  by  the  vegetations  which 
cover  the  vitelline  membrane  at  the  time  of  the  entrance  of  the  ovule  into 
the  uterus.  No  vessels  have  yet  appeared,  but  they  carry  nutritive  matter 
from  the  uterus  to  the  vitellus  by  endosmotic  action.  The  second  chorion  is 
formed  by  the  external  layer  of  the  blastoderm,  which  is  composed  of  cells 
resulting  from  the  segmentation  of  the  vitellus.  This  layer,  by  gradual  pres- 
sure against  the  vitelline  membrane,  at  first  lines  it,  and  then  causing  its  ab- 
sorption becomes  itself  the  external  envelope  of  the  ovum  or  the  second  cho 
rion.  The  third  chorion  is  formed  by  the  allantoid,  which  is  applied  to  the  inter 
nal  surface  of  the  preceding  chorion,  and  causing  its  atrophy  by  pressure,  becomes 
the  external  membrane  of  the  ovum  which  remains  until  the  end  of  gestation.  This 
membrane  is  at  first  covered  entirely  by  vascular  villi  which,  at  a  later  period, 
remain  only  at  the  place  where  the  placenta  is  developed. 

We  thus  find  that  these  three  parts  are  developed  in  the  order  mentioned;  but 
the  second  chorion  is  not  absorbed  ;  it  remains,  on  the  contrary,  until  the  foetal  evo- 
lution is  completed,  lined  on  its  internal  surface  by  the  allantoid.  the  vascular 
loops  of  which  enter  the  villi  of  the  second  chorion. 

Consequently  the  allantoid  never  becomes  a  chorion,  meaning  thereby  the  exter- 
nal layer  of  the  ovum,  nor  is  there  any  other  chorion  properly  so  called  than  the 
second  one  formed  by  the  external  layer  of  the  blastoderm  ;  inasmuch  as  the  vitel- 
line membrane  does  not  deserve  the  name,  although  after  the  example  of  Bae'r  and 
Coste,  it  has  been  applied  to  it  by  some  authors.  The  vitelline  membrane  exists, 
indeed,  only  before  the  formation  of  the  embryo,  and  disappears  as  soon  as  the  lat- 
ter and  its  amniotic  membrane  become  perceptible,  leaving  exposed  the  imperforate 
layer  of  the  blastoderm,  which  takes  the  name  of  chorion.  (Robin.  Journal  de 
1  hysiologie,  1861.] 

But  be  that  as  it  may,  the  chorion  certainly  does  not  exhibit  the  same 
aspect  at  the  advanced  stages  of  pregnancy:  for  during  early  embryonic 
existence  the  external  membrane  of  the  ovum  is  thin,  transparent,  and  per- 
fectly smooth  on  its  outer  surface,  whilst  about  the  second  week  this  surface 
presents  some  minute  granular  elevations,  which  increase  in  length  very 
rapidly,  and  the  chorion  soon  becomes  studded  with  numerous  villi.  But  at 
that  time  neither  the  chorion  nor  the  villi  have  a  proper  vascular  apparatus, 
since  it  is  not  until  after  the  allantois,  together  with  the  umbilical  vessels, 
has  become  applied  to  the  chorion,  that  vessels  can  be  detected  going  from 
this  membrane  to  penetrate  the  villi. 

The  chorion  is  enveloped  in  a  great  measure  by  the  reflexed  or  epichorial 
dccidua,  which  separates  it  from  the  parietal  decidua;  and  is  in  contact,  by 
a  restricted  surface,  with  a  portion  of  the  mucous  membrane  which  con- 
stitutes the  utero-epichorial  or  inter-utero-placental  decidna.  There  is  at 
the  outset  a  considerable  space  between  its  external  surface  and  the  internal 
one  of  the  pouch  containing  it,  which  space  is  occupied  by  its  villi,  and  may 
become,  as  we  shall  see,  the  seat  of  a  considerable  effusion  of  blood. 

Those  villi  which  are  in  contact  with  the  reflected  dccidua,  penetrate  at 
first,  as  they  increase  in  size,  into  the  substance  of  that  membrane;  they 
13 


194  PREGNANCY. 

booh,  however,  become  atrophied,  and  dwindle  away  almost  completely,  the 
interval  disappears,  and  the  two  membranes  come  into  immediate  contact. 

As  regards  the  villi  of  the  chorion,  not  covered  by  the  reflected  decidua, 
bo  far  from  being  atrophied,  they  speedily  undergo  a  considerable  develop- 
ment, when  they  are  in  contact  with  the  thickened  and  softened  uterine 
mucous  membrane  (utero-placental  decidua),  and,  intercrossing  with  the 
numerous  vessels  developed  in  its  substance,  contribute  to  the  formation  of 
that  essentially  vascular  mass  we  are  about  to  describe  under  the  name  of 
placenta. 

The  chorion  is  in  apposition  by  its  internal  face  with  the  amnios  at  an 
advanced  period  of  pregnancy  ;  but,  as  previously  noticed,  these  two  mem- 
branes are  not  concentric  in  the  earlier  months,  being  then  separated  by  a 
considerable  space  that  is  occupied  by  the  umbilical  vesicle  and  an  albumi- 
nous liquid,  which  is  the  more  abundant  and  limpid  as  the  gestation  is  less 
advanced. 

After  the  development  of  the  placenta,  the  chorion  is  a  thin,  transparent, 
colorless  membrane,  united  outwardly  to  the  decidua  by  some  short,  delicate 
filaments,  the  remnants  of  the  atrophied  villi,  and  inwardly  to  the  amnios 
by  an  albuminous  layer  (tunica  media,  reticulated  body).  The  part  corre- 
sponding to  the  placenta  is  no  longer  in  immediate  contact  with  the  decidua; 
it  is  thicker,  and  adherent  to  the  foetal  surface  of  that  vascular  body,  and 
the  attachment  is  more  intimate  near  the  root  of  the  cord.  After  what  has 
already  been  stated,  it  were  idle  to  discuss  the  vascularity  of  the  chorion, 
f>r  it  evidently  has  no  vessels  until  after  the  allantois  has  been  developed ; 
but  from  that  period  it  consists  of  two  lamina?,  the  external  or  primitive  of 
which,  also  called  the  exochorion,  is  wholly  destitute  of  vessels,  whilst  the 
internal  or  allantoid  is  essentially  vascular,  and  has  been  denominated  the 
endochorion. 

ARTICLE    IV. 

OF   THE   ORGANS   OF   CONNECTION. 

§  1.  The  Placenta.     (After-birth,  Secimdines.') 

The  placenta  is  a  soft,  spongy  mass,  constituting  the  principal  connection 
between  the  ovum  and  uterus,  being  destined  to  the  hematosis,  and  perhaps 
also  to  the  nourishment  of  the  foetus. 

It  is  a  flattened  body,  about  three-quarters  of  an  inch  in  thickness  at  the 
centre ;  but  tapering  off  towards  the  circumference,  which  does  not  often 
exceed  two  or  three  lines ;  in  some  cases  it  is  very  thin,  but  then  it  is  very 
large,  and  further,  its  figure  and  dimensions  are  exceedingly  variable  ;  thus, 
the  ordinary  diameter  of  the  placenta  varies  from  six  to  eight  and  a  half 
inches,  at  times  one  diameter  is  longer  than  the  others,  and  the  shape,  there- 
fore, is  circular,  oval,  &c,  according  to  circumstances.  The  term  battle- 
door-placenta  has  been  applied  to  that  variety  in  which  the  cord  is  inserted 
on  the  border.  As  a  general  rule,  only  one  placenta  exists  in  simple  preg- 
nancies. However,  a  very  curious  exception  was  observed  quite  recently  at 
the  Clinique  of  the  Berlin  Hospital,  namely,  a  double  placenta  for  a  single 
•mild.     Dr.  Ebert   furnishes   the   following  description  of  this   anomaly  ■ 


DEVELOPMENT   OF   THE    HUMAN    OVUM. 


195 


When  displayed  on  a  table,  it  was  found  to  be  divided  into  two  exactly 
equal  rounded  parts,  which  were  entirely  distinct,  having  no  connection 
whatever  with  each  other,  excepting  through  the  intervention  of  the  cord 
and  membranes ;  an  interval  of  about  three  inches  separated  the  two  por- 
tions. The  cord  was  twenty-one  inches  long,  containing,  as  in  the  normal 
state,  the  three  vessels  spirally  arranged,  but  this  spiral  form  ceased  nearly 
two  inches  from  the  bifurcation  of  the  umbilical  vein,  at  this  point  the  two 
arteries  were  placed,  one  on  each  side  of  the  vein,  and  only  communicated 
by  a  trifling  anastomosis. 

The  vein  bifurcated  about  four  inches  from  the  placenta ;  the  two  result- 
ing branches  were  of  unequal  length,  and  the  longest  sent  a  branch  to  the 
opposite  placenta.  The  arteries  had  a  similar  arrangement,  one  being  sent 
to  each  after-birth.  The  one  corresponding  with  the  longest  vein  likewise 
sent  a  branch  to  the  other  placenta,  but  the  interior  subdivisions  of  the 
vessels  offered  no  further  anomaly. 

The  membranes  formed  a  single  cavity  for  the  fcetus  and  amniotic  waters ; 
they  invested  the  two  portions  of  the  cord,  the  fcetal  face  of  both  placentas, 
and  passed  from  one  organ  to  the 

oilier,  thus  establishing  a  kind  of  fiu.m. 

membranous  bridge  between  them, 
which,  with  the  cord,  was  the  sole 
point  of  communication  between 
these  two  masses.  (Arch.  G&n., 
1842,  t.  xiv.) 

A  similar  case  has  recently  oc- 
curred at  the  Clinique  d' Accouche- 
ment de  Paris,  a  drawing  of  which 
has  been  prepared  by  M.  P.  Dubois. 

A  placenta  presenting  the  same 
anomaly,  was  recently  exhibited  by 
me  to  the  Biological  Society.  This 
specimen  derived  additional  interest 
from  the  fact,  that  it  was  the  pro- 
duct of  a  double  pregnancy,  the 
other  ovum  having  a  distinct  and 
regularly  formed  placenta. 

A  much  more  singular  case  has  been  obligingly  communicated  to  me  by 
Dr.  Blot.  In  this  instance,  the  placental  mass  presented  nearly  the  usual 
appearance,  but  around  it  were  distributed  several  entirely  distinct  cotyle- 
dons, which  were  connected  with  it  only  by  the  vessels  proceeding  from 
them  to  join  the  ramifications  of  the  cord.     (Fig.  64.) 

The  after-birth  presents  a  fcetal,  or  internal,  and  an  external,  or  uterine 
surface;  also  a  circumference,  or  border.  The  internal  surface  is  covered 
both  by  the  chorion  and  amnion,  and  exhibits  numerous  ramifications  of  the 
umbilical  arteries  and  vein,  which  generally  converge  about  the  centre  of 
this  body  to  form  the  umbilical  cord.  The  uterine  surface  is  much  les? 
smooth,  polished,  and  uniform  than  the  preceding,  and  ia  slightly  convex. 
whilst  the  former  is  a  little  concave.     It  is  subdivided  into  a  variable  uuin^ 


Placenta,  with  five  separate  Cotyledons. 
Chorion,    b.  Amnion,    c.  The  Cord.    d.  Separata 
cotyledons. 


196 


PREGNANCY. 


ber  of  lobes,  or  irregularly  rounded  cotyledons,  held  together  by  a  lamel- 
lated,  apparently  albuminous  tissue,  which  is  so  easily  lacerated,  that,  a  rup- 
ture may  occur  during  the  separation  of  the  placenta,  so  that  after  its 


Fig.  68. 


Fig.  65.    The  internal,  or  foetal  surface  of  the  placenta. 
FIG.  t'6.     The  external,  or  uterine  surface  of  the  placenta. 

expulsion,  the  cotyledons  appear  to  be  separated  from  each  other  by  deep 
furrows  or  fissures.  This  surface  is  covered  by  a  thin  layer  of  adhesive 
matter  through  which  the  reddish  and  sanguinolent  appearance  of  the  coty- 
ledons is  perceptible. 

The  placental  circumference  is  thin  and  irregular,  and  its  extent,  although 
very  variable,  is  generally  about  twenty-five  inches.  The  margin,  accord- 
ing to  M.  Velpeau,  is  continuous,  without  a  well-marked  line  of  demarcation, 
with  the  double  lamina  formed  by  the  folding  of  the  deciduous  membrane. 
But  in  the  opinion  of  other  anatomists,  the  periphery  of  this  vascular  mass 
is  continuous  with  the  chorion,  and  only  contiguous  to  the  double  fold  of 
the  decidua,  which  is  there  thicker  and  more  dense,  and  presents  a  kind  of 
triangular  sinus  for  the  reception  of  the  placental  border. 

Our  future  remarks  upon  the  structure  of  the  placenta  will  serve  to  show 
that  its  circumference  is  continuous  with  both  the  chorion  and  the  decidua; 
with  the  chorion  by  its  foetal  portion,  which,  after  all,  is  formed  by  the 
h ypertrophied  villi  of  the  chorion  ;  and  with  the  decidua  or  parietal  mucous 
;nombiane  by  its  maternal  portion,  which  is  but  a  thickened  part  of  this 
same  uterine  mucous  membrane. 

[Structure.  —  That  we  may  not  be  misled  whilst  studying  the  structure  of  the 
placenta,  I  think  it  best  to  state  briefly  the  mariner  in  which  it  is  formed. 

The  history  of  its  development  shows  that  it  formed  of  the  villi  of  the  chorion, 
the  growth  and  ramification  of  which  give  rise  to  innumerable  filaments  which 
ingraft  themselves  upon  the  intermediate  mucous  membrane  to  which  they  soon 
adhere  closely.  The  maternal  vessels  undergoing  an  inverse  development  form 
vast  numbers  of  loops,  which  descend  between  the  villi  of  the  chorion  and  extend 
to  the  foetal  surface  of  the  placenta.  An  amorphous  matter  is  soon  deposited 
between  the  villi  of  the  chorion  uniting  them  together,  and  the  placenta  thus 
formed  is  at  the  same  time  a  maternal  and  fcetal  organ. 

The  separation  of  the  placenta  after  delivery  takes  place  at  the  most  superficial 
portion  of  the  intermediate  mucous  membrane.     (See  Inter-utero-placental  Decidua.) 


DEVELOPMENT    OF    THE    HUMAN    OVUM.  197 

The  foetal  placenta  comes  entirely  away,  bringing  with  it  the  epithelial  layer  (if  the 
inter-utero-placental  decidua  and  the  placental  distribution  of  the  maternal  vessels. 
The  thickest  part  of  the  intermediate  mucous  membrane  remains,  on  the  contrary, 
attached  to  the  uterus.     (See  Decidua,  and  Lying-in  stale.) 

Such,  in  short,  are  the  principal  phenomena  which  occur  during  the  development 
and  separation  of  the  placenta,  and  they  will  serve  to  guide  us  amidst  the  different 
opinions  which  have  been  advanced  respecting  the  structure  of  the  organ.] 

The  structure  of  the  after-birth  has  been  a  theme  of  numerous  discussions 
among  embryologists ;  but  the  researches  of  MM.  Blandin,  Jacquemier, 
Flourens,  and  Bonami,  in  our  own  times,  and  even  yet  more  recently  those 
of  Reid,  Weber,  Coste,  Eschricht,  and  Robin,  have  thrown  much  light  on 
this  subject. 

We  have  sought  laboriously  for  the  truth  amongst  these  different  opinions; 
and  in  believing  that  we  have  found  it  in  the  facts  established  by  M.  Robin, 
we  are  no  less  convinced  that  the  task  has  been  greatly  facilitated  by  the 
researches  of  his  predecessors.  In  order  to  render  justice  to  all,  we  consider 
it  our  duty  to  give  an  analysis  of  the  principal  investigations  which  have 
been  made  in  reference  to  this  interesting  point  of  ovology. 

If,  while  the  placenta  is  still  adherent  to  the  uterine  wall,  a  careful  effort 
be  made  to  detach  it,  we  can  easily  see  that  this  detachment  takes  place  at 
the  expense  of  a  particular  tissue,  which  at  once  separates  and  holds  the 
two  surfaces  in  contact.  Now,  this  utero-placental  substance  is  of  an  albu- 
minous or  membranous  nature,  and  is  composed,  according  to  Robin,  of  the 
epithelium  of  the  intermediate  decidua.  This  membranous  layer  (that  has 
also  been  accurately  described  by  M.  Jacquemier)  is  moulded,  as  it  were, 
on  the  irregular  surface  of  the  placenta,  to  which  the  adhesion  is  more  per- 
fect than  to  the  corresponding  part  of  the  womb ;  it  dips  into  the  fissures 
that  separate  the  cotyledons,  unless  these  should  happen  to  be  very  deep,  in 
which  case  it  merely  passes  from  one  lobe  to  another,  thereby  forming  a 
6pecies  of  membranous  bridge;  but  a  partition  of  the  same  nature  much 
thicker  than  the  preceding  penetrates  deeply  between  the  lobes.  The 
lamina  clothing  the  external  surface  of  the  placenta  is  continuous  with  the 
decidua,  without  exhibiting  any  other  difference,  says  the  same  author,  than 
a  considerable  augmentation  of  thickness ;  a  disposition  that  is  apparently 
mechanical,  being  due  to  the  relief  made  by  the  projecting  circumference 
of  the  after-birth,  and  which  thus  determines  around  that  organ  a  greater 
accumulation  of  plastic  material.  According  to  that  able  anatomist,  this 
membrane  offers  all  the  physical  characters  of  the  decidua ;  and  he  seems 
quite  disposed  to  consider  them  both  as  being  one  and  the  same. 

This  inter-utero-placental  tissue  is  traversed  by  a  greal  number  of  venous 
and  arterial  vessels,  which  pass  from  the  internal  surface  of  the  uterus  to 
the  placenta  (utero-placental  vessels);  but  it  does  not  appear  to  be  th:> 
ultimate  termination  of  a  single  blood-vessel.  No  trace  of  the  injection 
remained,  in  this  tissue,  in  the  preparations  just  alluded  to,  made  by  M. 
Bonami. 

Let  us  proceed,  however,  to  the  vascular  structure  of  the  placenta,  pro- 
perly so  called;  and,  as  1  have  witnessed  the  injections  of  M.  Bonami,  I 
cannot   do  better  than   transcribe   here    the   following    parts  of   his  thesis : 


198  PREGNAXCY. 

"  An  injection,  composed  of  spirit-varnish,  colored  with  red-lead,  was  first 
thrown  into  the  venous  system  of  the  uterus  through  the  primitive  iliac  and 
one  of  the  ovarian  veins.  A  second,  consisting  of  spirits  of  turpentine  and 
iudigo,  was  then  made  of  the  uterine  arteries  through  the  inferior  extremity 
of  the  aorta,  ligatures  being  previously  placed  on  all  the  vessels  capable  of 
transmitting  the  injected  fluids  to  the  inferior  extremities. 

"  The  uterine  cavity  having  been  opened  at  some  distance  from  the 
placenta]  insertion,  and  the  foetus  stripped  of  its  membranes,  a  blackish 
liquid,  which  was  nothing  but  the  blood,  was  next  squeezed  from  the  vessels 
of  the  coid;  then  injections,  having  linseed-oil  colored  with  white-lead  and 
yellow  ochre  as  their  base,  were  thrown  into  the  umbilical  vein,  and  into 
one  of  the  arteries." 

These  injections  were  made  with  the  greatest  possible  precaution,  and  the 
following  results  were  afterwards  obtained  from  a  careful  dissection :  "  At 
first,  the  red  liquid  injected  into  the  uterine  veins  could  be  distinctly  per- 
ceived on  the  foetal  surface  of  the  placenta.  But,  by  what  canals  could  the 
injection  have  penetrated  so  far  as  this?  Here  was  a  new  subject  of 
research ;  but,  by  carefully  turning  the  placenta  aside,  a  considerable 
number  of  small  vessels  could  easily  be  recognized,  leaving  the  internal 
surface  of  the  womb,  traversing  the  inter-utero-placental  tissue  just  described, 
and  plunging  into  the  substance  of  the  placenta.  These  consisted  of  arteries 
and  veins,  readily  cognizable  as  such  by  the  different  colored  injections." 

1st.  Arteries. — The  number  of  these  is  large,  and  they  are  more  abundant 
near  the  centre  of  insertion  than  anywhere  else;  still,  a  few  very  delicate 
ones  are  found  about  an  inch  from  the  placental  circumference.  Generally, 
they  are  quite  small,  varying  from  a  fourth  of  a  line  to  a  line  in  diameter. 
They  assume  very  sensibly  a  spiral  arrangement,  and  their  course  is  oblique, 
almost  always  creeping  along  for  a  third  of  an  inch,  sometimes  more,  before 
their  terminal  extremities  are  directed  towards  the  anfractuosities  of  the 
placenta ;  and  they  evidently  penetrate  the  proper  substance  of  the  latter, 
though  towards  the  uterus  they  are  clearly  continuous  with  the  uterine 
arteries.  Lastly,  they  have  but  few  ramifications,  and  these  rarely  anasto- 
mose with  each  other. 

2d.  The  veins  pass  from  the  uterus,  through  the  inter-utero-placental 
membrane,  towards  the  placenta,  but  they  have  not  the  same  disposition  as 
the  arteries. 

The  calibre  of  these  veins,  says  M.  Bonami,  is  nearly  equal  to  that  of  the 
arteries,  sometimes  even  a  little  larger,  some  of  them  being  from  two  to 
three  lines  in  diameter.  The  characters  by  which  we  could  distinguish 
these  from  the  arteries,  were  conclusive  in  the  piece  under  examination. 
Thus,  these  veins  were  penetrated  by  liquids  thrown  into  the  uterine  venous 
system  ;  they  were  rectilinear,  and  their  exceedingly  numerous  ramifications 
anastomosed  freely  with  each  other,  thereby  forming  vast  plexuses  on  the 
cell-walls,  which  penetrated  the  uterine  surface  of  the  placenta  at  all  points; 
and,  on  the  other  hand,  by  further  dissection,  could  be  seen  with  the  naked 
eye  terminating  in  the  large  uterine  veins.  Besides  these,  according  to 
Meckel  and  Jacquemier,  there  exists  a  vein  which  encircles  the  periphery 
of  the  placenffl  ;  but   this  coronary  vein  is  rarely  complete,  as  it  nearly 


DEVELOPMENT   OF   THE    HUMAN    OVUM.  199 

always  exhibits  one  or  more  interruptions  of  an  inch  or  two  in  extent, 
although  its  continuity  is  sustained  by  a  series  of  veins  anastomosing  with 
one  another,  and  its  course  exhibits  numerous  varicose-like  dilatations.  It 
communicates,  at  short  distances,  with  the  uterine  veins,  and  receives  con 
tributions  both  internally  and  externally ;  some  of  these  spread  over  the 
uterine  surface  of  the  placenta,  and  anastomose  with  the  veins  that  penetrate 
this  body  at  its  centre;  the  others,  which  are  less  numerous,  ramify  in  the 
substance  of  the  decidua,  two  or  three  inches  from  the  circumference  of  the 
placenta.  M.  Robin  says  that  it  resembles  a  uterine  sinus,  and  is  more 
properly  one  of  the  latter  excavated  in  the  mucous  membrane  than  a  true 
vein.  The  presence  of  this  coronary  vein  is  not  constant,  for  neither  Vel- 
peau  nor  Bonami  have  ever  met  with  it. 

There  are,  therefore,  certain  arteries  and  veins  that  penetrate  the  placenta, 
belonging  to  the  maternal  vascular  system  ;  but  before  studying  their  dis- 
tribution, let  us  examine  that  of  the  umbilical  vessels.  These,  consisting 
of  the  umbilical  arteries  and  vein,  having  arrived  at  the  fcetal  surface  of 
the  placenta,  divide  into  several  large  branches  that  are  found  between  the 
amnion  and  chorion.  The  first  of  these  membranes  may  be  detached  with 
great  facility;  but  the  second  intimately  adheres  to  the  vessels,  which  it 
completely  envelops,  thus  forming  a  sheath  in  which  one  artery  and  one 
vein  are  always  found,  the  vein  being  much  the  larger ;  shortly  after,  each 
trunk  divides  into  two  branches,  each  of  these  into  two  others,  and  thus 
they  go  on  subdividing  dichotomously  almost  ad  infinitum.  The  two 
umbilical  arteries  communicate  freely  with  each  other  in  the  substance  of 
the  same  cotyledon,  and  this  anastomosis  may  even  be  seen  without  the  aid 
of  an  injection.  Again,  if  a  coarse  injection  be  thrown  into  one  of  the 
arteries,  it  will  shortly  return  by  the  other ;  though,  if  the  pressure  be  con- 
tinued, it  will  pass  from  the  arteries  into  the  umbilical  vein ;  but  if  we 
commence  by  filling  the  vein,  the  injection  reaches  the  arteries  with  more 
difficulty.  If  a  very  penetrating  mixture  be  used,  the  whole  uterine  surface 
of  the  placenta  will  be  converted  into  a  very  delicate  plexus,  which  never 
affords  an  outlet  to  the  injected  liquid ;  patulous  orifices  do  not  exist,  there- 
fore, at  the  extremities  of  the  vessels. 

When  a  placenta  has  been  thus  injected,  and  is  then  macerated,  it  soon 
appears  to  resolve  itself  into  a  substance  resembling  woolly  flakes  covered 
by  numerous  particles  of  a  soft  pulpy  tissue,  that  is  detached  from  them 
with  much  difficulty.  These  flakes  present  under  the  microscope  a  large 
number  of  granulations,  composed  of  small,  convoluted,  twisted  vessels,  like 
those  in  the  chorial  villi  of  the  cow  or  the  sheep.  These  small  granules 
have  been  described  as  acini,  or  little  grains.  The  vessels  become  longer 
as  the  maceration  is  continued,  and  finally  lose  flexuosity  almost  entirely. 

On  the  whole,  therefore,  the  placenta  is  formed  by  vessels  belonging  to 
the  mother  as  well  as  by  those  appertaining  to  the  child,  and  each  of  its 
cotyledons  is  constituted  in  the  following  manner:  the  maternal,  or  utero- 
placental vessels  penetrate  at  all  points  of  its  uterine  surface,  forming  in  ita 
hubstance  a  net-work  of  exceedingly  delicate  meshes,  while  the  umbilical 
vessels  that  penetrate  on  the  fcetal  surface  present  those  infinite  ramifica- 
tions just  described,  and  these  twist  around  and  em  brat  e  the  contracted 


200  PREGNANCY. 

meshes  of  the  maternal  plexus  in  all  directions.  Further,  the  connection 
existing  between  these  two  orders  of  vessels  appears  to  result  from  the  mem- 
branous sheath  that  envelops  them  both,  even  into  the  substance  of  the 
placenta. 

This  sheath  is  furnished  to  one  set  by  the  chorion,  to  the  other  by  the 
extremely  delicate  prolongations  of  the  maternal  vessels.  In  other  words, 
being  compressed  and  united  with  each  other  through  the  intervention  of  a 
common  substance,  these  divisions  and  subdivisions  form  a  cotyledon  of  the 
placenta. 

Again,  all  the  minute  vascular  ramuscles  are  so  intimately  connected 
that  it  is  impossible  to  separate  the  vessels  belonging  to  the  mother  from 
those  peculiar  to  the  foetus,  and  they  can  only  be  distinguished  from  each 
uther  by  the  different  colored  injections.  But,  although  the  two  series  thus 
interlace,  the  maternal  branches  never  communicate  by  their  terminal 
extremities  with  those  of  the  foetus  ;  since  the  finest  injections,  when  most 
carefully  made,  have  never  established  a  direct  communication  between 
these  two  orders  of  vessels,  —  unless  by  rupture  of  the  walls. 

The  description  of  Eschricht  is  very  analogous  to  that  of  M.  Bonami ; 
thus,  the  former  concludes  that  two  orders  of  capillary  plexuses  are  in  con- 
tact in  the  human  placenta,  and  that  the  uterine  arteries  are  continuous 
with  the  veins  of  the  same  name  through  a  capillary  plexus,  equally  deli- 
cate with  the  one  existing  between  the  umbilical  arteries  and  veins. 

But  the  researches  of  Weber  have  led  to  different  conclusions  as  to  the 
mode  in  which  the  uterine  arteries  run  into  the  veins  of  a  similar  name  in 
the  placenta,  and  these  curious  results  deserve  some  notice,  inasmuch  as 
they  seem  to  form  a  natural  transition  to  the  arrangement  which  we  shall 
describe  hereafter. 

He  states  that  the  uterine  arteries  enter  the  after-birth  without  giving  off 
any  arborescent  ramifications  ;  and,  on  the  other  hand,  that  the  veins  do 
not  arise  by  delicate  ramuscles,  but  present,  at  their  very  origin,  large  trunks, 
which  by  anastomosing  with  each  other  very  frequently  and  at  all  points,  seem 
to  form  in  this  manner  a  system  of  cells,  whence  the  blood  then  passes  by 
some  venous  trunks  into  the  uterine  veins.  These  latter  are  continuous 
with  the  arterial  tubes  from  their  origin  ;  their  walls  are  excessively  thin  in 
the  placenta,  being  there  reduced  to  the  internal  coat,  and  collapse,  so  as  to 
be  nearly  invisible  when  they  contain  but  little  blood.  The  terminal  rami- 
fications of  the  umbilical  vessels  project  into  these  venous  sinuses;  more- 
over, the  thin  tunic  of  the  vein  is  pushed  into  the  interior  of  the  vessel  bv 
the  foetal  villus  resting  against  its  outer  surface,  and  it  thus  furnishes  a 
sheath  to  the  latter,  which  seems  to  penetrate  to  the  interior  even  of  the 
maternal  vascular  tube,  though  in  reality  it  does  not. 

Read,  in  August,  1840,  easily  verified,  he  says,  the  existence  of  the  utero- 
placental vessels,  when  examining  the  uterus  of  a  pregnant  woman,  who  died 
at  the  seventh  month. 

After  having  detached  a  portion  of  the  placenta  underwater,  my  atten- 
tion was  drawn  to  a  number  of  rounded  bands  passing  between  the  uterus 
and  the  external  surface  of  the  placenta.  When  the  least  traction  was 
made,  their  walls   became  thinner  as  their  length   increased,  and  had  a  eel- 


DEVELOPMENT  OF  THE  HUMAN  OVUM.  201 

iular  appearance,  though  they  were  easily  lacerated ;  whilst  sometimes, 
though  more  rarely,  they  seem  to  separate  like  the  tufts  of  the  uterine  sin- 
uses. By  cutting  into  one  of  the  sinuses,  these  tufts  could  be  traced,  and 
Been  to  ramify  in  its  interior ;  some  seemed  to  penetrate  the  patulous  open- 
ing of  the  sinus  only,  while  others  sank  in  for  about  an  inch,  and  appeared 
to  penetrate  even  the  surrounding  sinuses.  I  could  easily  satisfy  myself  by 
injection  and  microscopical  inspection,  that  these  tufts  were  the  ultimate 
ramifications  of  the  umbilical  vessels. 

It  is  scarcely  necessary  to  add,  that  these  tufts  only  penetrate  the  open- 
ings of  the  sinuses  situated  near  the  internal  surface  of  the  uterus,  and  not 
those  more  deeply  seated.  Their  volume  varies  very  much,  some  appearing 
to  fill  the  opening  of  the  sinus  entirely,  whilst  others  only  occupy  it  in  part. 
Again,  although  the  tufts  appeared  loose,  and  floating  in  the  interior  of  the 
maternal  vascular  tube,  yet  they  were  evidently  surrounded  by  the  internal 
tunic  of  the  latter,  which  was  reflected  on  their  external  surface. 

I  have  assured  myself  that  some  of  the  utero-placental  veins  contained 
no  prolongation  of  the  foetal  vessels,  but  in  many  others  the  villous  tufts  (the 
terminations  of  the  umbilical  vessels)  could  be  recognized  and  followed  into 
the  uterine  sinuses. 

In  tracing  these  utero-placental  veins  that  contain  no  fcetal  vessels  through 
the  decidua  to  the  surface  of  the  placenta,  the  internal  membrane  of  such 
veins  is  found  prolonged  on  the  neighboring  placental  tufts ;  and  further, 
by  following  a  large  utero-placental  artery  through  the  decidua,  we  may  see 
that  as  soon  as  it  arrives  on  the  face  of  the  placenta,  its  internal  tunic  is 
prolonged  on  certain  tufts  that  are  found  plunged  in  its  orifice. 

The  numerous  branches  of  the  foetal  tufts  which  stop  at  the  placental  sur- 
face of  the  decidua,  and  neither  penetrate  into  the  uterine  sinuses,  nor  yet 
into  the  orifices  of  the  utero-placental  vessels,  are  fixed  by  their  extremities 
to  the  placental  surface  of  this  membrane.  Consequently,  the  placenta  is 
formed  interiorly  by  numerous  trunks  and  branches  (each  containing  an 
artery  and  a  vein),  and  each  of  these  branches,  both  venous  and  arterial, 
is  surrounded  by  a  prolongation  of  the  internal  tunic  belonging  to  the 
maternal  vascular  system,  or  at  least  by  a  membrane  continuous  with  that 
tunic.  Hence,  in  adopting  such  ideas  of  the  placental  structure,  it  becomes 
evident  that  the  internal  tunic  of  the  mother's  vessels  is  prolonged  on  each 
placental  tuft,  in  such  a  manner  that  the  maternal  blood,  arriving  by  the 
utero-placental  arteries,  passes  into  a  large  sac  formed  from  the  internal 
lamina  of  these  vessels,  and  the  blood  is  thus  divided  into  a  thousand  dif- 
ferent directions  by  the  placental  villi,  which  project  like  fringes  into  these 
vessels,  pressing  in  their  thin,  soft  parietes  before  them,  and  forming  sheaths 
therefrom  which  completely  envelop  each  trunk  and  each  branch.  The 
blood  returns  from  this  sac  by  the  utero-placental  veins  without  any  extra- 
vasation or  abandonment  of  the  vascular  system  to  which  it  properly  belongs. 
Therefore,  the  foetal  blood,  and  that  of  the  mother,  can  have  no  action  upon 
each  other,  excepting  through  the  spongy  parietes  of  the  foetal  vessels  and 
the  thin  sac  that  surrounds  them. 

It  will  be  seen  that  but  a  single  step  has  now  to  be  taken  in  order  to 
reach  the  description  given  by  M.  Coste. 


202 


PREGNANCY 


It  is  really  impossible  to  obtain  a  correct  idea  of  the  structure  and  devel- 
opment of  the  placenta,  without  being  acquainted  with  the  nature  and 
structure  of  the  villi  of  the  chorion,  as  also  with  the  changes  undergone  by 
that  portion  of  the  uterine  mucous  membrane  (utero-epichorial  decidual 
upon  which  the  ovule  is  ingrafted. 

a.  Villi  of  the  Chorion.  —  We  have  already  stated  that  before  the  allantoic! 
is  developed,  each  villus  of  the  chorion  contains  a  canal,  which  is  open  at 
its  base,  but  terminates  in  a  cul-de-sac  at  its  free  extremity  ;  after  the  allan- 
toid  is  developed,  the  terminal  ramifications  of  the  umbilical  vessels,  both 
arteries  and  veins,  penetrate  into  this  canal  as  into  the  finger  of  a  glove. 
The  villi,  after  having  been  thus  rendered  vascular,  become  atrophied,  and 


This  figure  represents  the  manner  in  which  the  villi  of  the  chorion  ramify.  —  0  C.  Trunk  of  the  villus. 
E.  Terminal  ramification  intact.     O.  A  terminal  branch  broken  off.     V.  A  lateral  branch. 

finally  disappear  from  all  that  part  of  the  chorion  which  is  covered  by  the 
reflected  or  epichorial  decidua.  Those,  on  the  contrary,  which  are  in  imme- 
diate contact  with  the  utero-epichorial  mucous  membrane  (inter-utero- 
placental  decidua  of  authors),  undergo  a  considerable  development,  and 
ramify  ad  infinitum.  When  viewed  collectively  at  this  period,  they  have 
the  appearance  of  a  soft,  hairy  mass,  very  tufted  and  flaky,  and  of  a  semi- 
transparent  gray  rose-color. 

If  the  villi  which  compose  this  hair-like  mass  of  the  chorion  be  separated 
from  each  other  and  examined,  the  following  characters  will  be  found 
Applicable  to  all:  a  common  pedicle,  forming  the  base  or  trunk  of  the 
villus,  about  one-sixteenth  of  an  inch  long,  and  one-half  as  wide,  for  an 
ovum  of  six  week-,  the  dimensions  varying,  however,  with  the  size  cf  the 
ovum.  From  this  pedicle  are  pul  forth  numerous  branches,  forming  a 
bulky  tuft.  The  largest  of  these  branches,  after  dividing  two  or  three 
times,  are  again  subdivided  into  innumerable  minute  branchlets. 


DEVELOPMENT     OF     THE     HUMAN     OVL'M.  203 

Again,  some  of  the  smaller  branches  stand  alone  upon  the  surface  of 
the  chorion,  in  the  interspaces  of  the  tufted  pedicles  just  mentioned. 

The  extremities  of  the  subdivisions  of  the  third  and  fourth  orders  are 
here  and  there  found  to  present  a  sort  of  cylindric  or  flattened  swelling. 

One  of  the  principal  subdivisions  of  the  umbilical  arteries  and  veins  is 
distributed  to  each  of  these  pedicles,  and  extends  into  all  of  its  branches, 
ramifying  as  it  goes. 

Inasmuch  as  the  branches  of  any  one  pedicle  have  no  communication 
with  those  of  a  neighboring  one,  it  follows  that  each  tuft  of  the  chorion  has 
a  circulation  of  its  own. 

Although  the  terminal  villi  become  longer,  their  thickness  is  not  sensibly 
increased,  for  their  diameter  is  nearly  the  same  after,  as  before  the  develop- 
ment of  the  placenta. 

B.  Utero-epichorial  Mucous  Membrane. — These  hypertrophied  villi  come 
in  contact  with  a  very  thick  and  much  softened  portion  of  the  uterine 
mucous  membrane.  As  they  grow  longer,  they  penetrate  into  the  tissue  of 
the  mucous  membrane  itself,  excavating  therein  a  species  of  cells  or  lacuna?, 
which  can  be  seen  without  difficulty  upon  the  bottom  of  the  receptacle 
represented  in  Plate  III.,  Fig.  53. 

Since  the  arteries,  but  more  especially  the  veins,  are  so  developed  at  this 
point  that  the  frequent  dilatations  of  the  latter  form  large  cavities  or  sinuses, 
from  one-eighth  to  one-quarter  of  an  inch  in  diameter,  the  vascular  villi  of 
the  chorion  necessarily  come  in  contact  with  the  walls  of  the  uterine  vessels. 
According  to  M.  Coste,  the  latter  are  even  worn  through  by  the  villi  of 
the  chorion,  which  having  thus  ga'ned  entrance  into  their  cavities,  are  sus- 
pended freely  in  the  blood  which  fills  them. 

Soon  these  infinitely  numerous  and  elongated  villi  become  united  to  each 
other  by  means  of  an  amorphous  substance,  which  is  deposited  in  small 
quantity  amongst  them,  so  as  to  give  to  each  tuft  of  the  same  pedicle  the 
compactness  which  each  placental  cotyledon  presents  at  a  more  advanced 
period  of  pregnancy. 

The  villi  taken  from  the  placenta  immediately  after  labor,  differ  from 
those  described  only  in  the  greater  number  of  their  ramifications,  and  the 
larger  size  of  the  pedicles  and  of  the  principal  branches  which  they  put  forth. 

The  foetal  portion  of  the  placental  tissue  is  formed,  in  short,  of  interlaced 
filaments,  which  are  simply  the  chief  branches  of  the  villi  of  the  chorion, 
whose  ramiiications  can  be  followed  to  their  termination  only  by  the  use  of 
a  lens,  so  inextricably  entangled  are  they,  and  agglutinated  by  the  amor- 
phous matter  of  which  we  have  spoken.  They  thus  form,  by  their  agglom- 
eration, a  tissue  of  a  reddish-gray  color,  soft,  elastic,  giving  way  to  pressure 
of  the  finger,  and  yielding  a  filamentous  fragment  by  tearing. 

The  structure  of  all  the  villi  is  not,  however,  identical  at  the  termination 
of  pregnancy.  Although  the  greater  number  preserve  until  the  end  the 
double  vascular  canal  which  they  presented  at  the  beginning,  the  vessels 
of  a  few  become  atrophied,  and  like  the  non-placental  villi,  finally  constitute 
a  very  slender  filament  devoid  of  a  canal.  Fig.  68,  for  which  I  am  indebted 
to  the  kindness  of  M.  Robin,  exhibits  these  dillerences,  besides  showing 


204 


PREGNANCY. 


very  clearly  the  admirable  disposition  of  the  fetal  vessel  within  the  riilua 
itself.1 

Thus  H  and  T  represent  a  terminal  prolongation  of  the  branches  of  a 
placental  villus,  ovoid  in  shape,  with  a  contracted  pedicle  and  obliterated 
cavity;  at  B  is  another  terminal  prolongation  of  the  same  villus,  having  the 
structure  which  almost  all  of  them  retain  in  the  placenta.  It  is  composed 
of  an  external  envelope  b,  or  wall  of  the  villus,  of  a  structure  identical  with 
that  of  the  chorion.  Its  thickness,  and  consequently  that  of  the  substance 
separating  the  blood  of  the  foetus  from  that  of  the  mother,  may  be  estimated 
approximative^.     It  is  about  '0004  of  an  inch. 

This  villus  presents  internally  a  partition,  a,  dividing  its  cavity  into  two 
vascular  tubes.  The  tubes  are  situated  beside  each  other,  like  the  barrels 
of  a  double-barrelled  gun  ;  they  bend  toward  each  other  at  a",  so  as  to  form 
a  single  canal  at  the  extremity  of  the  ^  illus,  which  is  arterial  at  d  e,  but 
venous  at  g'  g.  This  partition  a  has  only  half  the  thickness  of  the  external 
wall  b.  It  has  a  spur-like  termination  at  a",  and  adheres  by  its  base  at  a' 
to  the  wall  of  the  villus. 

When  this  disposition  of  the  terminal  ramifications  is  once  understood, 
all  discussion,  as  M.  Robin  remarks,  respecting  a  direct  communication 
between  the  maternal  and  foetal  vascular  systems,  is  ended. 

Each  of  the  capillary  vessels  of  this  double  canal  empties  into  a  corre- 
sponding one  of  larger  size,  at  the  point  of  junction  or  of  separation  of  a 
ramification  with  a  larger  branch  ;  for  example  (Fig.  68),  the  arterial  tube 

Fio.  68. 


The  figure  represents  a  fragment  of  the  villi  of  the  chorion  obtained  from  the  placenta.     It  exhibits 
prolongations  of  various  appearance.     Magnified  360  diameters. 

D  E  empties  at  a'  into  the  trunk  of  the  same  nature  of  the  principal  branch 
C  V,  and  the  venous  tube  g'  G  discharges  at  the  point  C. 

1  Tlio  minute  details  into  which  I  am  about  to  enter,  are  the  analysis  of  the  researches 
of  my  learned  colleague  and  friend,  M.  Robin.  They  are  for  the  most  part  recorded 
in  an  excellent  memoir  published  by  him,  and  also  in  the  thesis  of  M.  Cayla,  one  of 
(lis  pupils 


DEVELOPMENT    OF    THE    HUMAN*    OVUM.  205 

The  placenta  is  therefore  composed  of  two  parts,  which  are  very  distinct, 
in  a  physiological  point  of  view,  although  they  are  confounded  in  a  single 
mass  at  the  end  of  gestation.  One  of  these  is  the  foetal  portion,  and  is  more 
especially  adherent  to  the  chorion,  from  which  it  takes  its  origin ;  the  other 
the  maternal  portion,  is  a  greatly  thickened  part  of  the  uterine  mucous 
membrane. 

It  is  very  difficult  to  say  what  is  the  real  mode  of  connection  between 
these  two  elements  of  the  placenta,  since  such  different  results  have  followed 
the  dissections  of  the  most  skilful  anatomists. 

Their  continuity,  or  direct  communication,  is  at  present,  however,  out  of 
the  question,  for  all  are  united  in  regarding  their  relation  as  one  of  simple 
contact,  a  greater  or  less  extent  of  adhesion. 

[The  foregoing  represents  what  was  known  until  within  a  few  years  past,  of  the 
structure  of  the  placenta.  More  recently,  Professor  Robin,  who  at  first  accepted 
the  ideas  of  M.  Coste,  has  changed  his  opinion  on  the  subject,  and  we  have  now  to 
state  his  present  views.     (Various  memoirs  and  oral  communications.) 

A  close  examination  of  the  external  surface  of  the  placenta,  will  soon  show  that 
the  entire  surface  of  the  cotyledons  is  covered  by  a  grayish,  semi-transparent,  and 
soft  membrane,  from  the  ^5  to  the  ^  of  an  inch  in  thickness  in  different  specimens. 
This  membrane,  whose  existence  we  have  already  asserted,  is  sometimes  smooth, 
sometimes  rough,  quite  elastic  and  adhesive,  and  of  a  peculiar  appearance.  It 
passes  without  interruption  from  one  cotyledon  to  another,  being  only  rather  thicker 
in  the  interstices.  It  is  formed  by  the  epithelium  of  the  inter-utero-placental  mucous 
membrane  in  its  thickened  and  hypertrophied  condition.  A  few  other  elements, 
derived  from  the  most  superficial  portion  of  the  same  mucous  membrane,  are  also 
found  in  it,  such  as  laminated  fibres,  amorphous  matter,  and  molecular  granules  of 
various  kinds. 

This  layer  represents  the  maternal  placenta,  and  is  traversed  by  a  profusion  of 
maternal  capillary  vessels  which  pass  into  the  body  of  the  placenta.  If  these 
vessels  be  followed  into  the  soft,  grayish,  and  glutinous  layer,  just  described,  we 
find  that  they  become  gradually  flatter  and  more  irregular;  they  are  distributed 
over  the  convex  surface  of  the  cotyledons  and  in  their  interstices,  and  at  all  these 
points  enter  deeply  in  an  oblique  direction  toward  the  foetal  surface  of  the  placenta. 
In  pursuing  this  course,  their  walls  become  so  extremely  thin  that  they  are  often 
discerned  with  great  difficulty.     (Robin.      Communications  orales.) 

Having  entered  the  placental  tissue,  they  dilate  and  communicate  so  largely  as 
to  form  throughout  the  entire  mass  of  the  placenta  a  pool  of  blood,  which  bathes 
the  entire  placental  surface  of  the  chorion  at  the  point  of  attachment  of  the  pedicle 
of  each  villus. 

This  expanse  of  blood  penetrates  the  fine  sponge-like  interstices  between  the 
reticulated  ramifications  of  the  villi,  but  nowhere  is  there  any  direct  communication 
between  the  maternal  and  foetal  blood. 

Beneath  the  preceding  layer  is  found  the  foetal  placenta,  which  constitutes  the 
greater  bulk  of  the  organ  and  is  formed  by  the  expansion  of  the  villi  of  the  chorion 
agglutinated  by  amorphous  matter.  Amongst  these  villi  are  distributed  the 
numerous  maternal  vessels. 

The  glutinous  layer,  formed  by  the  epithelium  of  the  serotina  at  the  surface  of  the 
placenta,  is  always  present,  unless  accidentally  removed:  thus  proving  the  very 
important  fact  that  the  placental  villi  are  not  plunged  freely  by  means  of  floating 
extremities  in  the  sinuses  of  the  serotina.  The  cotyledons,  it  is  true,  project  toward 
the  utero-placental  mucous  membrane  which,  in  its  turn,  penetrates  somewhat  into 
the  furrows  which   separate  the  cotyledons:   still,  their  convex  surfaces  are  merely 


206  PREGNANCY. 

applied  against  the  sinnses  of  the  serotina.  which  glide  between  the  villi  in  ordei 
to  open  into  the  above-mentioned  pool  of  blood  resulting  from  the  enormous  dilata- 
tion and  tha  destruction  here  and  there  of  the  walls  of  the  capillaries  of  the  super- 
ficial net-work  of  this  part  of  the  mucous  membrane. 

The  adhesion  between  the  cotyledons  and  the  mucous  membrane  is  molecular 
and  so  intimate,  that,  instead  of  merely  separating  from  the  latter,  it  brings  away 
with  it  the  superficial  layer  of  the  serotina. 

Notwithstanding  this,  it  is  true  that,  in  an  anatomical  point  of  view,  the  cotyle- 
dons, in  fact  the  placenta,  are  merely  applied  by  the  surface,  against  the  inter- 
mediate mucous  membrane.  The  foetal  villi  are  not  plunged  in  the  form  of 
arborescent  or  radical  branches  in  the  tissue  of  the  serotina,  as  all  the  descriptions 
would  seem  to  indicate,  but  it  were  more  correct  to  regard  the  maternal  blood  as 
seeking  them  at  a  certain  depth  in  the  mass  of  the  cotyledons.] 

The  placenta  appears  to  be  destitute  of  nerves  and  lymphatic  vessels. 

All  the  cotyledons  composing  the  placental  mass  are,  as  we  have  said, 
united  by  the  interlobular  membrane.  Occasionally,  however,  one  or  several 
of  these  lobes  are  separated  from  the  others,  and  seem  to  form  another 
placenta  by  their  isolation ;  in  this  way  it  has  happened  that  several 
placentas  have  been  attributed  to  a  single  fetus,  and,  perhaps,  the  facts 
mentioned  at  the  beginning  of  this  article  are  to  be  accounted  for  in  the 
same  way. 

The  placenta  may  be  inserted  upon  any  part  of  the  uterine  cavity,  and 
even  upon  its  orifice,  though  most  usually  it  is  fixed  near  the  fundus  of  the 
organ.  It  has  been  customary  to  account  for  these  varieties  of  insertion,  by 
eaying  that  the  latter  is  determined  by  the  most  vascular  portion  of  the 
organ  ;  overlooking  the  fact,  that,  although  the  point  of  attachment  be 
indeed  more  vascular  than  any  other  part  of  the  uterine  parietes,  it  is 
simply  because  of  the  insertion,  thus  confounding  the  cause  with  the  effect. 
According  to  some  authors,  the  weight  of  the  ovule  determines  the  point  of 
insertion  of  the  placenta,  which,  if  true,  should  most  frequently  take  place 
upon  the  neck.  Observation,  however,  refutes  this  opinion.  Finally,  accord- 
ing to  MM.  Moreau  and  Velpeau,  when  the  ovule  enters  the  womb,  it  is 
obliged  to  separate  the  decidua  from  the  wall  of  the  uterus,  and  therefore 
naturally  tends  towards  the  points  of  least  resistance. 

The  details  which  we  have  given  respecting  the  mode  of  formation  of  the 
decidua,  show  that  the  latter  opinion  is  without  foundation.  The  following 
seems  to  us  to  be  the  most  probable  explanation :  Generally,  by  the  time 
the  ovule  enters  the  uterine  cavity,  the  latter  is  filled  to  repletion  by  the 
folded  and  swollen  mucous  membrane.  This  state  of  things  renders  it 
almost  impossible  that  it  should  progress  very  far,  and  the  consequence  is, 
that  in  the  vast  majority  of  cases  it  lodges  in  one  of  the  numerous  folds 
neat  the  fundus,  and  becomes  attached  in  the  vicinity  of  the  orifice  of  the 
tube  by  which  it  entered.  The  placenta  is,  in  fact,  generally  found  in  this 
neighborhood.  Why,  in  some  cases,  it  should  be  situated  in  the  inferior 
segment  of  the  womb,  is  of  more  difficult  explanation,  except  upon  the  sup- 
position that  fecundation  was  effected  after  the  arrival  of  the  ovule  in  the 
uterine  cavity;  in  which  case,  in  consequence  of  the  less  swollen  condition 
of  the  mucous  membrane,  it  may  have  been  able  to  obey  the  laws  of  gravity 
immediately  upon  entering  the  cavity,  and  thus  descend  towards  the  lowest 
points. 


DEVELOPMENT    OF    THE    HUMAN    OVUM.  207 

Sometimes  the  insertion  of  the  placenta  upon  the  lower  segment  of  the 
aterus  occurs  in  several  successive  pregnancies.  Ingleby  relates  one  case  in 
which  it  happened  three  times,  and  says  he  knew  the  same  thing  to  occur 
ten  times  in  another.  M.  Dunal,  from  whom  I  quote  the  above,  gives  an 
observation  of  M.  Menard,  in  which  the  woman  had  this  unfavorable  inser- 
tion twice  consecutively.  Whether  this  sort  of  habit  can  depend  upon  a 
peculiar  disposition  of  the  Fallopian  tube  or  of  the  uterus,  is  a  question 
which  anatomical  research  only  is  competent  to  decide. 

§  2.  The  Umbilical  Coed. 

The  umbilical  cord  is  the  flexible  trunk,  which  unites  the  abdomen  of 
the  child  to  the  placenta;  it  does  not  exist  during  the  early  weeks  of  preg- 
nancy, and  its  formation  only  commences  when  the  embryo  is  completely 
separated  from  the  blastodermic  vesicle,  which  thereby  becomes  the  umbili- 
cal vesicle;  when  the  allantois,  by  being  confounded  with  the  external 
lamina  of  the  blastoderm,  no  longer  constitutes  a  distinct  vesicle,  but  i9 
merely  a  simple  cord  upon  which  the  two  umbilical  arteries  and  the  vein 
ramify ;  and  when  all  these  parts  have  received  an  enveloping  sheath  from 
the  amnios.  Now  it  scarcely  appears  thus  formed  until  towards  the  end  of 
the  first  month,  being  composed  at  this  period,  in  all  normal  embryos  of  the 
age  of  the  one  which  we  shall  describe  (page  210),  of  three  distinct  parts : 
1,  of  an  enveloping  canal,  whose  walls  are  formed  by  a  reflection  of  the 
amnios,  and  which  is  continuous  at  the  umbilicus  with  the  skin  of  the 
embryo ;  2,  of  two  pedicles  proceeding  from  the  fcetal  appendages,  around 
which  this  amniotic  canal  forms  a  sheath,  and  which  communicate,  the  one 
under  the  name  of  the  pedicle  of  the  umbilical  vesicle,  with  the  ileo-ccecal 
fold  of  intestine,  and  the  other,  under  the  name  of  urachus,  or  the  pedicle 
of  the  allantois,  with  the  bladder. 

But  soon  after,  as  the  development  progresses,  and  the  pedicle  of  the 
umbilical  vesicle  is  absorbed,  the  cord  becomes  simplified,  and  is  reduced 
to  the  amniotic  sheath  and  the  urachus,  accompanied  by  the  umbilical  ves- 
sels, with  which  this  sheath  is  confounded  by  the  obliteration  of  the  canal 
that  constitutes  it.  The  effacement  of  this  canal,  along  which  only  the 
urachus  and  its  accompanying  vessels  pass,  progresses  from  the  chorial 
extremity  of  the  cord  towards  the  umbilicus,  or  abdomen  of  the  embryo ; 
and,  as  the  progressive  obliteration  approaches  the  latter,  it  encounters  the 
intestine  which  advances  beyond  the  umbilicus,  and  forms  a  hernia  in  the 
cord  itself;  but  this  rupture  is  naturally  reduced,  in  consequence  of  the 
pressure  exercised  on  the  bowel  by  the  progress  of  effacement,  which  ulti- 
mately reaches  the  navel,  and  presses  back  into  the  abdomen  everything 
met  with  outside  of  its  cavity.  However,  in  some  instances  this  process  is 
not  completed  in  so  efficacious  a  manner,  and  the  intestine  in  such  cases 
remaining  beyond  the  umbilicus,  produces  the  malformation  known  as  con- 
genital hernia;  a  hernia  that  is  nothing  more  than  the  persistence  of  an 
inatomical  disposition,  which  always  exists  temporarily  at  a  certain  period 
of  the  embryonic  life. 

The  cord,  at  the  end  of  the  first  month,  is  still  thin,  cylindrical,  and  very 
small;    but  from  the  fourth   to   the  eighth,   and  even   the  ninth   week,   it 


208  PREGNANCY. 

acquires  a  considerable  proportional  volume;  and  it  exhibits  either  som« 
enhirgements,  vesicles,  or  swellings,  two,  three,  or  four  in  number,  whicn 
are  separated  from  each  other  by  a  corresponding  number  of  bands,  or  con- 
tractions. 

During  the  third  month  it  diminishes  in  size,  in  consequence  of  a  retrac- 
tion of  these  tuberosities ;  but  again,  commencing  from  this  latter  period, 
it  continues  to  grow  proportionally  to  the  other  parts  of  the  foetus  until  the 
end  of  gestation. 

The  cord  varies  greatly  in  length  at  term  :  generally,  it  is  from  twenty- 
one  to  twenty-three  inches ;  some  have  been  observed,  however,  from  six 
inches  to  five  feet  (one  metre  fifty-three  centimetres)  ;  others,  still  more 
rare,  have  reached  five  feet  nine  inches  in  length  (one  metre  seventy-five 
centimetres).  I  delivered  a  woman  with  the  forceps,  June  23,  1841,  in 
whom  the  head  had  been  retained  above  the  superior  strait,  and  where  the 
cord  was  only  nine  inches  long.  These  extremes  are  very  rare;  neverthe- 
less, they  are  not  the  utmost  varieties  the  cord  may  offer  in  its  extreme 
limits,  for  it  has  been  known  not  to  exceed  five  inches,  and  has  even  been 
as  short  as  two  inches. 

In  a  case  reported  by  Mende,  it  was  so  short  that  the  placenta  absolutely 
seemed  fixed  to  the  child's  abdomen.  Its  size  likewise  varies  in  different 
subjects,  being  generally  about  that  of  the  little  finger,  sometimes  much 
smaller,  and  at  others  very  large ;  but  in  all  these  cases  its  volume  depends 
much  less  on  that  of  the  vessels  than  on  the  quantity  of  fluids  accumulated 
in  the  surrounding  tissue. 

The  nerves  and  lymphatic  vessels,  which  certain  authors  have  described 
as  belonging  to  the  cord,  are  still  a  subject  of  research  ;  admitted  by  some 
and  denied  by  others,  their  existence  is  at  least  problematical. 

The  arteries  are  two  in  number,  and,  following  the  course  of  the  blood, 
they  arise  from  the  bifurcation  of  the  abdominal  aorta  in  the  fcetus,  and 
reach  the  umbilicus,  whence  they  traverse  the  entire  length  of  the  cord, 
describing  numerous  flexuosities  as  far  as  the  placenta,  in  the  tissue  of  which 
we  have  already  followed  their  ramifications. 

The  vein,  still  following  the  route  of  the  blood,  arises  from  the  numerous 
minuscules  studied  in  the  placenta ;  the  venous  radicles  of  each  lobe  unite 
to  form  branches,  which  in  their  turn  aggregate  on  the  foetal  surface  of 
the  after-birth,  to  form  there  the  trunk  of  the  umbilical  vein  ;  and  the  latter, 
having  arrived  at  the  umbilical  ring,  abandons  the  two  arteries,  and  run9 
towards  the  Fiver.  (See  Circulation  of  the  fcetus.)  The  vein  is  nearly  equal 
in  size  to  the  two  arteries  united;  but  it  is  much  less  flexuous,  and  conse- 
quently its  course  is  shorter. 

These  vessels  are  wound  upon  each  other  in  a  way  nearly  similar  to  the 
twigs  of  osier  forming  the  handle  of  a  basket ;  they  give  off  no  branches  in 
the  cord,  and  it  has  been  remarked  that  the  twisting  of  the  vessels,  which 
only  begins  after  the  second  month,  takes  place,  nine  times  in  ten,  from  left 
to  right.  The  vein  usually  occupies  the  axis  of  the  cord,  and  the  arteries 
wind  uniformly  around  it.  Of  course,  this  enrolling  must  depend  somewhat 
on  the  torsions  of  the  embryo  itself,  and  then  the  entire  cord,  together  with 
"ts  sheath,  is  involved,  as  not  unfrequently  happens;  but  when  the  cord  ia 


DEVELOPMENT     OF     THE     HUMAN     OVUM. 


209 


straight,  and  the  arteries  are  twisted  at  least  more  than  it  is,  these  contortions 
seem  to  result  from  a  more  rapid  growth  of  the  vessels  within  the  sheath, 
than  of  the  sheath  itself  (Haller).  Now,  the  embryo  and  placenta  being 
immovable,  the  turns  starting  from  these  two  points  will  necessarily  meet 
each  other,  and  this  indeed  frequently  takes  place.  Two,  and  even  three 
umbilical  veins  have  been  met  with  in  some  cases  ;  in  others,  instead  of  twc 
arteries  there  is  but  one.  Osiander  once  found  three  of  the  latter.  It  is 
worthy  of  remark,  that  neither  the  arteries  nor  the  veins  have  valves  at 
any  part  of  their  course. 

These  vessels  are  surrounded  by  a  gelatinous  substance  called  Wharton's 
gelatine,  which  is  variable  in  its  quantity,  thereby  giving  rise  to  the  division 
made  by  accoucheurs  into  the  thin  and  fat  cords.  This  substance  is  con- 
tinuous on  one  part  with  the  sub-peritoneal  cellular  tissue  of  the  foetus,  and, 
on  the  other,  accompanies  the  vessels  into  the  placenta.  Being  spongy  in 
character,  it  is  constituted  by  a  clear,  tenacious  liquid,  contained  in  the 
cellular  areolae,  that  communicate  so  freely  with  each  other.  The  cord 
frequently  has  one  or  more  knots  when  it  is  very  long,  some  of  which  are 
formed  during  pregnancy,  and  often  even  at  an  early  stage;  but  others  arc. 
only  produced  at  the  period  of  labor:  they  never  become  so  tightened  (in 
gestation)  as  to  compromise  the  life  of  the  child,  to  Avhose  movements  they 
are  certainly  due;  but  we  can  understand  that  the  cord  may  become  tightly 
drawn  during  labor,  from  being  shortened  by  circular  turns  around  the 
trunk  or  neck  ;  the  knots,  in  such  cases,  may  be  so  hardened  as  to  intercept 
the  circulation  completely,  and  the  death  of  the  foetus  will  necessarily  result 
if  the  labor  be  prolonged.  In  one  case,  figured  in  the  work  of  M.  Baude- 
locque,  the  cord  was  knotted  three  times  at  the  same  place,  and  was  inter- 
laced like  a  mat.1 

M.  Soete,  an  accoucheur  at  Gheluwe,  has  described  a  very  singular  case 
of  double  pregnancy,  in  which  the  two 
foetuses  were  inclosed  in  the  same  bag, 
and  the  two  cords  formed  a  perfect  knot 
with  each  other. 

Besides  these  knots,  true  nodosities 
likewise  exist  at  times  in  the  cord,  pro- 
duced either  by  the  duplicature  or  the 
varicose  state  of  one  of  its  vessels. 

We  have  already  stated  that  the  cord 
is  attached  by  one  extremity  to  the 
umbilicus  of  the  child,  and  by  the  other 
to  some  point  of  the  foetal  surface  of  the 
placenta ;  but  this,  however,  is  not  always 
the  case,  for  the  facts  are  too  numerous 

which    go   to    prove    that   the    cord    may  An  anomaly,  described  by  Benckteer. 

indeed  be  inserted  on  the  head,  neck,  shoulders,  and  other  parte  of  the 


Fig.  69. 


1  The  ancients  thought  they  could  determine  the  fecundity  of  the  female  by  these 

knots:  thus,  according  to  Avicenna.  the  more  knots  the  more  will  be  the  future  con 
ceptions;  and  if  they  occur  at  some  distance  apart,  the  pregnancies  will  also  he  more 
distant  from  each  other.  —  (fsrselis  Spachii  gynieeeorum  lihri.) 
14 


210  PREGNANCY. 

foetal  trunk,  not  to  admit  some  of  them,  at  least ;  such,  for  example,  as  the 
one  observed  by  M.  Jules  Cloquet,  at  Brussels.  The  placental  extremity 
of  the  cord  also  presents  some  anomalies ;  it  is  usually  fixed  very  near  the 
centre,  but  sometimes  is  found  attached  to  a  part  of  the  periphery,  bearing 
then  the  title  of  the  battledoor-placenta.  Nor  is  it  always  attached  to  a  point 
of  the  foetal  surface  of  the  placenta.  For  instance,  Benckiser  has  collected 
in  his  thesis  numerous  cases  in  which  the  cord  was  inserted  at  some  point 
on  the  periphery  of  the  membranes;  and  having  arrived  there,  the  vessels 
of  the  cord  then  divide  into  five  or  six  large  trunks,  the  branches  of  which, 
by  ramifying  between  the  membranes,  reach  the  placental  circumference, 
and  plunge  into  the  parenchyma  of  this  body.     (See  Fig.  69.) 

All  such  modifications,  however,  merely  depend  on  the  way  in  which  the 
allantois  contracts  its  adhesions  with  the  point  of  the  ovum  in  contact  with 
the  womb.  In  fact,  the  placenta  is  always  developed  there,  and  if  the 
allantois  happens  to  strike  the  chorion  at  a  point  somewhat  removed  from 
that  which  is  in  apposition  with  the  internal  uterine  surface,  the  umbilical 
vessels  must  evidently  have  a  tendency  towards  the  latter,  just  as  the  roots 
of  a  plant  always  stretch  towards  the  spot  which  will  afford  them  the  most 
nourishment. 


CHAPTER  Y. 

OF   THE   FCETUS. 

We  shall  not  attempt  to  study  the  foetus  by  describing  the  different 
organs,  and  the  various  tissues  successively,  that  enter  into  its  structure  at 
the  moment  of  birth,  nor  by  tracing  each  of  them  through  the  modifications 
it  undergoes  at  the  divers  periods  of  the  intra-uterine  life;  for  such  a  course 
would  evidently  compel  us  to  overstep  the  limits  imposed  by  the  nature  and 
character  of  this  work.  Therefore,  laying  aside  all  embryological  researches, 
we  shall  content  ourselves  with  mentioning  a  few  interesting  particulars  of 
organogeny;  and  while  considering  the  foetus  in  a  general  manner,  we  shall 
point  out  succinctly  the  successive  development  of  its  form  and  its  external 
parts.  But  before  entering  upon  this  subject,  we  believe  it  will  prove 
profitable  to  present,  in  a  figure,  the  various  details  already  furnished,  as 
such  an  exposition  will  complete  the  description  previously  made,  and 
facilitate  a  knowledge  of  the  facts  we  have  yet  to  speak  of. 

EXPLANATION  OF   THE   FIGURES   IN   PLATE   III. 

lie.  1.  The  human  ovum,  of  its  natural  size,  at  about  the  thirtieth  or  thirty-sixth 
day. 

Fig.  2.  The  Bame  ovum  (of  its  natural  size)  laid  open  to  show  its  constituent  parts. 

a  a.  The  chorion. 

n.  The  amnion. 

c.  The  foetus. 

i).  The  umbilical  vessel. 

Pig,  3.  The  same  ovum  highly  magnified,  and  opened  in  such  a  way  as  to  exhibit 
the  principal   relations  existing  between  the  embryo  and  its  appendages.      The  walls 


>?W- 


I 


Fig. 


JC 


■-W 


•a&ftl 


r/"I'?^%, 


4       K    O  M. 


OF    THE    FCETUS.  211 

of  the  abdomen  an  J  chest  have  been  cut  away  so  as  to  bring  the  viscera  into  view,  and 
the  umbilical  cord  has  also  been  split  up,  for  the  purpose  of  showing  how  the  appen- 
dages of  the  foetus  are  brought  into  relation  with  this  latter. 

a  a.  The  chorion,  consisting  of  two  layers,  placed  back  to  back,  and  confounded 
with  each  other,  but  which  have  been  dissected  apart  for  a  limited  extent  at  a/  a'. 

b  b.  The  amnion,  laid  open,  so  as  to  show  how  it  is  continuous  with  the  umbilical 
cord,  along  which  it  is  reflected,  thereby  forming  a  sheath,  which,  under  the  form  of 
•  the  canal  b'  b',  is  directly  continuous  with  the  umbilicus  or  the  abdominal  walls  c  0 
of  the  embryo. 

d.  The  umbilical  vesicle,  and  d'  its  pedicle. 

d//.  The  point  where  this  pedicle  communicates  with  the  intestine  e. 

e.  The  loop  of  intestine  prolonged  into  the  cord. 

f.  The  urachus,  continuous  by  one  extremity,  g,  with  the  chorion,  and  by  the  other 
with  the  rectum  at  the  point  h. 

ii.  The  umbilical  arteries. 

j.   The  umbilical  vein. 

y.   The  part  of  the  right  auricle  from  which  the  umbilical  vein  comes  off. 

k.   The  vena  cava  inferior. 

m.  The  inferior  surface  of  the  liver. 

n.  The  omphalo-mesenteric  vein. 

0.  The  point  where  this  vein  empties  into  the  umbilical  vein, 
p.   The  omphalo-mesenteric  artery. 

1.  The  heart. 

2.  The  arch  of  the  aorta. 

3.  The  pulmonary  artery. 

4.  The  lung  of  the  right  side. 
5    The  Wolffian  body. 

6.  The  branchial  fissure,  which  is  converted  into  the  external  ear. 

7.  The  lower  jaw. 

8.  The  upper  jaw. 

9.  The  nostril  of  the  right  side. 

10.  The  nasal  canal  still  forming  a  kind  of  fissure,  which  extends  from  the  eye  to 
he  nostril. 

11.  The  caudal  extremity,  or  coccyx,  projecting  like  a  tail. 

12.  The  upper  extremity. 

13.  The  lower  extremity. 

ARTICLE  I. 

DIMENSIONS   AND    WEIGHT    OF    THE    FffiTUS   AT   THE    DIFFERENT    PERIODS 
OF   INTRA-UTERINE   LIFE. 

At  the  time  when  the  embryo  first  begins  to  be  distinct,  that  is,  about 
the  third  week,  it  is  oblong,  swollen  in  the  middle,  obtuse  at  one  extremity, 
though  drawn  to  a  blunt  point  at  the  other,  and  straight,  or  nearly  so,  being 
somewhat  curved  forwards.  It  is  therefore  vermiform  in  shape,  of  a  grayish- 
white  color,  semi-opaque,  almost  without  consistence,  and  gelatinous,  vary- 
ing from  two  to  four  lines  in  length,  and  weighing  one  or  two  grains.  At 
this  period,  the  only  trace  of  the  head  is  a  small  tubercle  separated  from  the 
rest  of  the  body  by  a  notch,  but  no  rudiments  of  the  extremities  are  observed, 
nor  is  there  a  cord  at  first. 

The  embryo  is  clearly  surrounded  by  the  amnion,  which  lies  quite  near 
it,  in  the  form  of  a  delicate  membrane,  leaving  it,  however,  always  free. 
The  abdominal  cavity  is  opened  for  a  very  considerable  extent  in  front. 
The  embryo  becomes  more  consistent  towards  the  fifth  week:  its  head  then 


212  PREGNANCY. 

increases  greatly,  in  proportion  to  the  remainder  of  the  body,  and  the 
rudimentary  eyes  are  indicated  by  two  black'spots  turned  towards  the  sides; 
the  development  of  the  thoracic  extremities  is  announced  by  two  small, 
obtuse  nipples,  situated  on  the  sides  of  the  trunk ;  it  is  nearly  two-thirds  of 
an  inch  long,  and  weighs  about  fifteen  grains ;  the  cord  exists  in  a  rudi- 
mentary condition,  and  the  abdominal  members  are  likewise  present,  in  the 
form  of  two  rounded  pimples.  The  vertebral  divisions  are  quite  apparent, 
all  along  the  back,  although  the  caudal  vertebra;  closely  approach  the  front 
part  of  the  head,  in  consequence  of  the  anterior  curvature  of  the  embryo. 

Already  does  the  heart  exhibit,  in  its  external  form,  a  tolerably  close 
resemblance  to  that  in  the  adult ;  for  we  may  even  now  observe  the  fissure 
that  will  afterwards  separate  the  auricles,  as  also  one  corresponding  to  the 
inter-ventricular  partition ;  but  there  is,  in  reality,  only  one  ventricle,  from 
which  both  the  aorta  and  the  pulmonary  artery  arise.  And,  further,  there 
is  but  one  auricle  ;  or,  rather,  the  two  communicate  so  freely  that  the  inter- 
mediary contraction  which  should  divide  them  is  still  very  imperfect ;  for 
the  partition  is  formed  by  the  progressive  contraction  of  the  orifice  of  com- 
munication, and  this  incomplete  opening,  which  sometimes  persists  in  the 
septum  until  birth,  is  known  under  the  name  of  the  foramen  of  Botal.  But, 
after  birth,  the  opening  becomes  obliterated,  and  the  two  auricles  are  thence- 
forth isolated  by  a  complete  partition. 

The  single  ventricle  will  be  converted  into  two  cavities,  by  the  interven- 
tion of  a  septum,  which  will  be  gradually  developed  from  the  summit 
towards  the  base,  being  placed  between-  the  two  arteries  (the  pulmonary 
and  aorta),  and  so  disposed  that  one  of  them  shall  open  into  the  right  and 
the  other  into  the  left  cavity. 

The  lungs  at  this  period  are  constituted  of  five  or  six  lobules,  in  which 
we  can  readily  distinguish  the  bronchial  extremities,  terminating  in  slightly 
swollen  cul-de-sacs.  Moreover,  two  large  glandular  structures  lie  along  the 
vertebral  column  at  this  period,  extending  longitudinally  on  each  side,  from 
the  lung  to  the  bottom  of  the  pelvis.  These  are  the  Wolffian  bodies.  They 
are  constituted  by  an  excretory  canal,  which  runs  throughout  their  whole 
length,  being  placed  on  their  external  margin,  and  terminating  below  in 
the  transitory  cloaca.  The  canal  puts  forth,  on  one  of  its  sides  only,  a 
series  of  more  or  less  elongated  coeca,  which  roll  or  curl  up,  so  as  to  form  a 
considerable  mass  by  their  agglomeration.  These  coeca  secrete  a  liquid, 
which  is  subsequently  emptied  into  the  cloaca  by  means  of  the  canal. 

The  Wolffian  bodies  anticipate  the  function  of  the  kidneys  until  the 
latter  are  developed,  and  hence  they  have  been  denominated  the  false 
kidneys;  but  they  disappear  as  soon  as  the  true  organs  can  replace  them, 
leaving  no  trace  of  their  past  existence.  Just  alongside  of  the  excretory 
canal,  in  the  Wolffian  body,  a  second  one  is  seen  to  accompany  it  through- 
out, and  even  in  like,  manner  to  empty  into  the  cloaca.  But  this  second 
canal  is  perfectly  distinct  from  the  other,  and  will  become,  in  the  adult, 
either  the  oviduct  or  the  vas  deferens,  according  as  the  new  being  shall  be 
of  the  male  or  female  sex. 

In  the  early  stages  of  embryonic  life,  there  likewise  exists  on  each  side 
of  the  neck  in  the  human  fetus,  as  also  in  the  mammalia,  four  transverse 


OF    THE    FCETUS.  213 

fissures  which  open  into  the  pharynx.  These  are  separated  from  one  another 
by  certain  bands,  or  fleshy  partitions,  that  correspond  with  the  branchial 
arcs  of  fishes ;  for  the  vascular  apparatus  distributed  there  affects,  to  a  cer- 
tain extent,  the  same  form  temporarily,  that  it  has  permanently  in  the  inferior 
vertebrate.  We,  therefore,  see  that  the  bulb  of  the  aorta,  instead  of  curv- 
ing immediately  in  a  single  arch,  divides,  on  the  contrary,  into  three  or 
four  branches,  on  each  side  of  the  neck  ;  and  after  these  branches  have  each 
accompanied  a  branchial  arch,  they  reunite,  at  a  common  point,  to  form  the 
descending  aorta;  however,  they  are  soon  effaced,,  along  with  the  corre- 
sponding fissures,  and  but  two  remain  on  the  left  side,  one  of  which  is  con- 
verted into  the  arcus  aortse,  while  the  other,  after  having  existed  as  an 
arterial  canal,  will  form  the  common  trunk  of  the  pulmonary  arteries. 

The  branchial  fissures  just  under  consideration  also  disappear,  with  the 
exception  of  a  single  one  (the  first  on  each  side),  which  is  converted  into  the 
external  ear,  as  may  be  seen  in  the  figure.     (See  Plate  IV.) 

At  this  period,  the  upper  jaw  is  still  composed  of  two  papula?  one  for  each 
side.  These  pimples,  or  isolated  mandibles,  gradually  approach  the  median 
line,  and  there  unite  in  a  single  body,  which  forms  the  jaw  such  as  we  find 
it  in  the  adult. 

The  nostrils  are  separated  by  the  incisive  papulse,  which  keep  them  apart 
for  some  time ;  then,  as  the  latter  diminish  in  size,  they  approach  each  other 
and  assume  their  definitive  form  ;  but,  in  the  meanwhile,  they  are  separately 
split  down  to  the  mouth,  and  it  is  the  permanence  of  this  transitory  state 
that  constitutes  the  double  hare-lip.  All  of  the  branchial  fissures  have 
disappeared  by  the  sixth  week,  leaving  only  a  slight  cicatrix  behind. 

The  first  centres  of  ossification  appear  during  the  seventh  week,  first  on 
the  clavicle  and  then  on  the  lower  jaw.  The  intestine  still  extends  for  a 
considerable  distance  along  the  interior  of  the  umbilical  cord,  but  the 
omphalo-mesenteric  canal  is  nearly  obliterated,  although  it  may  yet  be 
traced  as  far  as  the  umbilical  vesicle,  where  it  is  reduced  to  a  very  delicate 
thread.  The  anus  remains  closed  ;  and  the  bodies  of  Wolff  alone  exist  near 
the  vertebral  column.  It  is  only  then  that  the  kidneys  and  capsular  renales 
begin  to  appear,  and  soon  after  them  the  sexual  organs.  The  urinary 
bladder  is  first  manifested  under  the  form  of  a  tumor  that  is  continuous 
with  the  urachus.     At  this  time,  the  embryo  is  nearly  an  inch  in  length. 

At  two  months,  the  tubercles  of  the  extremities  become  more  prominent. 
The  fore-arm  and  hand  can  be  distinguished,  but  not  the  arm ;  the  hand  is 
larger  than  the  forearm,  but  it  is  not  supplied  with  fingers.  The  cord  has 
not  as  yet  assumed  a  spiral  arrangement,  but  it  is  infundibuliform  in  shape, 
the  base  corresponding  to  the  abdomen,  being  continuous  with  it,  and  con- 
taining a  large  quantity  of  intestine;  it  is  four  to  five  lines  in  length,  and 
is  inserted  near  the  lowest  point  of  the  abdomen.  A  small  tubercle,  fur- 
nished with  one  or  more  very  contracted  openings,  may  be  distinguished 
between  it  and  the  termination  of  the  spine,  which  are  the  rudimentary 
external  organs  of  generation  ;  but  the  extreme  length  of  the  clitoris  renders 
the  distinction  of  the  sexes  difficult  at  this  period. 

The  embryo  is  from  one  and  a  half  to  two  inches  long,  and  weighs  fiom 
three  to  five  drachms,  the  head  forming  more  than  one-third  of  the  whole. 


214  PREGNANCY. 

The  eyes  are  prominent,  but  the  lids,  from  being  ttill  rudimentary,  do  i»o« 
cover  the  eyeball ;  the  nose  forms  an  obtuse  eminence ;  the  nostrils  are 
rounded  and  separated ;  the  mouth  is  gaping,  and  the  epidermis  can  be 
distinguished  from  the  true  skin. 

At  ten  weeks,  the  embryo  is  from  one  and  a  half  to  two  and  a  half  inches 
in  length,  and  weighs  an  ounce  or  an  ounce  and  a  half.  The  palpebral, 
having  become  more  apparent,  descend  in  front  of  the  eye,  and  the  puncta 
lachrymalia  are  now  visible  ;  the  buccal  fissure,  which  has  increased  in  size 
begins  to  be  obliterated  by  the  commencing  development  of  the  lips. 

The  thoracic  parietes  are  apparent ;  hence  the  heart's  movements  cease  to 
be  visible.  The  fingers  are  distinct,  and  the  toes  look  like  little  tubercles 
held  together  by  a  soft  substance.  The  cord  is  longer  than  the  embryo,  and 
begins  to  assume  the  spiral  arrangement ;  it  is  less  infundibuliform  than 
previously,  and  is  not  inserted  so  low  down  on  the  abdomen,  but  its  base 
always  contains  a  portion  of  intestine. 

At  the  end  of  the  third  month,  the  embryo  weighs  three  to  four  ounces,  and 
measures  from  five  to  six  inches ;  the  eyeball  is  seen  through  the  lids ;  the 
membrana  pupillaris  is  more  manifest ;  the  forehead  and  nose  are  clearly 
traceable,  and  the  lips  well  marked  and  not  turned  outwards.  The  neck 
now  establishes  a  visible  separation  between  the  head  and  thorax ;  the  latter 
cavity  is  closed  at  all  points,  but  is  still  very  slightly  developed  relatively 
to  the  other  cavities.  The  cord  contains  no  intestine,  and  its  spiral  turns 
are  more  numerous  and  evident.  The  nails  begin  to  appear  as  thin  mem- 
branous plates  ;  the  sex  is  distinct,  and  the  integuments,  which  heretofore 
were  only  a  soft,  viscous  covering,  acquire  more  consistence,  but  are  still 
very  thin,  transparent,  of  a  roseate  hue,  and  without  an  apparent  fibrous 
texture. 

At  the  fourth  month,  the  embryo  takes  the  name  of  foetus;  its  growth  is 
not  so  rapid  in  the  commencement  as  at  the  end  of  this  month.  The  body 
is  six  to  eight  inches  in  length,  and  weighs  from  seven  to  eight  ounces. 
The  fontanelles  are  very  large,  as  are  also  the  sutures;  and  some  short, 
whitish,  silvery  hairs  may  be  observed  on  the  head.  The  face  still  remains 
but  little  developed,  although  more  elongated  than  it  has  previously  been. 
The  eyes,  nostrils,  and  mouth  are  closed,  and  when  the  occlusion  of  the  lids 
happens  to  be  incomplete,  it  is  generally  at  the  internal  part.  The  tongue 
may  be  distinguished  behind  the  buccal  fissure,  and  the  projection  of  the 
chin  is  observable.  The  cord  is  inserted  higher  up  on  the  abdomen,  whence 
the  centre  of  the  body  is  an  inch  or  two  above  the  umbilicus.  The  skin  has 
a  rosy  color,  and  begins  to  be  covered  by  down  ;  and  some  fat,  tinged  with 
red,  is  deposited  in  the  areolae  of  the  subcutaneous  cellular  tissue,  and  the 
muscles  now  produce  a  sensible  motion.  A  foetus  born  at  this  period  might 
live  for  several  hours.  Whilst  I  was  Interne  at  the  Hotel  Dieu,  I  received 
one  that  had  scarcely  reached  the  fourth  month.  It  lived,  however,  from 
half-past  seven  to  half-past  eleven  o'clock. 

At  five  month.*,  the  length  of  the  body  is  eight  to  ten  inches,  and  it  weighs 
from  eight  to  eleven  ounces.  The  skin  is  more  consistent,  and  many  patches 
of  sebaceous  matter  may  already  be  seen,  but  the  pupils  cannot  be  dis- 
tinguished. 


OF    THE    FGETUS.  215 

At  six  months,  Uie  length  is  eleven  to  twelve  and  a  half  indies,  an<l  the 
weight  about  one  pound  (avoir.).  The  hair  is  both  longer  and  thicker,  the 
eyes  closed,  the  eyelids  somewhat  thicker,  and  their  margins,  as  well  as  the 
eyebrows,  are  studded  with  very  delicate  hairs.  Agreeably  to  most  authors, 
the  membrana  pupillaris  always  exists;  on  the  contrary,  the  pupil  at  this 
period  has  seemed  very  large,  both  to  M.  Velpeau  and  myself.  The  skin 
is  better  organized,  for  the  dermis  and  the  epidermis  may  be  distinguished, 
though  its  surface  is  wrinkled  and  puckered,  owing  to  the  small  quantity 
of  subcutaneous  fat.  The  nails  are  solid  already.  The  scrotum  is  very 
small,  quite  red,  and  empty. 

At  seven  months,  the  foetus  acquires  a  length  of  twelve  and  a  half  V: 
fourteen  inches  ;  all  its  parts  have  become  firmer  and  more  voluminous,  and 
their  respective  dimensions  better  proportioned.  The  bones  belonging  to 
the  vault  of  the  cranium  exhibit  near  their  centres  a  considerable  promi- 
nence at  the  point  where  the  first  rudiments  of  ossification  occur,  whence  it 
follows  they  are  less  uniformly  arched  than  at  the  succeeding  periods,  and 
more  curved  than  in  the  former  months,  when  they  were  in  reality  nearly 
flat.  The  pupillary  membrane  disappears  completely;  indeed,  according 
to  M.  Velpeau,  this  membrane  does  not  exist  at  any  period  jf  the  intra- 
uterine life.  The  iris  commences  as  a  simple  ring,  which  then  grows  in  a 
concentric  manner,  leaving  at  last  only  the  opening  called  the  pupil.  The 
eyelids  are  partly  open,  and  the  testicles  begin  to  descend  into  the  scrotum. 

At  eight  months,  the  foetus  seems  to  grow,  as  Desormeaux  remarks,  rather 
in  thickness  than  in  length  ;  it  is  only  sixteen  to  eighteen  inches  long,  and 
yet  weighs  from  four  to  five  pounds.  The  skin  is  very  red,  and  covered 
with  long  down,  and  a  considerable  quantity  of  sebaceous  matter.1  The 
lower  jaw,  which  was  at  first  very  short,  is  now  as  long  as  the  upper  one. 
The  scrotum  usually  contains  one  testicle,  generally  that  on  the  left  side. 

Finally  at  term,  the  foetus  is  about  nineteen  to  twenty-three  inches  long, 
and  weighs  from  six  to  seven  pounds.  Although,  in  consequence  of  the 
development  at  the  inferior  part  of  the  trunk,  the  umbilical  ring  is  now 
considerably  removed  from  the  hypogastric  region,  yet  the  insertion  of  the 
cord  does  not  correspond,  as  has  been  stated,  with  the  centre  of  the  body. 
Thus,  in  a  foetus  whose  total  length  is  twenty  inches,  we  shall  generally 
find  ten  and  a  half  to  eleven  inches  from  the  crown  to  the  umbilicus. 

Indeed,  from  the  researches  of  M.  Moreau,  communicated  to  the  Academy 
of  Medicine,  it  appears  that  in  ninety-four  children  born  at  nine  months, 
four  only  had  the  umbilical  insertion  in  the  middle  of  the  body,  while  in 

1  About  the  middle  term  of  t ho  Lntra-uterine  life,  the  skin  is  covered  by  a  constantly 
increasing  mass  of  a  fat,  slippery,  viscous  substance,  yellowish-white  in  color,  called 
the  sebaceous  coat.  This  substance  is  more  abundant  on  some  embryos  than  on  others, 
and  is  in  greater  quantity  on  certain  places,  as,  for  example,  the  bead,  axilla,  ami 

groins;  it  is  insoluble  in  water,  alcohol,  and  oil.  and  only  partially  soluble  in  potash. 
It  is  not  a  precipitate  furnished  by  the  amniotic  liquors,  as  some  persons  have 
imagined,  for  there  is  none  of  it  on  the  external  surface  of  the  amnios,  nor  on  the 
umbilical  cord  ;  it  is  a  secretion  of  the  foetal  skin,  and,  so  far  as  we  can  judge  by  its 
composition,  is  a  mixture  of  effete  epidermis  and  mailers  furnished  by  the  sebaceous 
glands,  which  assist  perhaps  in  (he  hour  of  labor  by  facilitating  the  expulsion  of  the 
child. 


216  PREGNANCY. 

ninety  others  it  was  below  this.  The  mean  of  the  variations  was  nearly  an 
inch.  M.  Ollivier,  of  Angers,  has  also  observed  the, same  thing  in  thirty 
children,  examined  by  him. 

The  weight  and  length  of  children  at  birth  have  been  wonderfully  exag- 
gerated in  many  cases;  thus,  some  are  recorded  of  a  yard  or  more  in  length, 
and  others  that  weighed  eighteen,  twenty,  twenty -four,  and  even  thirty 
pounds.  These  statements  must  certainly  be  great  exaggerations;  for  the 
most  voluminous  of  three  thousand  children,  born  under  my  charge,  eithei 
in  the  Hotel  Dieu  or  at  La  Clinique,  weighed  ten  pounds,  and  it  waf  an 
enormous  one. 

Of  four  thousand  children  delivered  at  La  Maternite,  one  only  weighed 
twelve  pounds.     (Lachapelle.) 

Baudelocque  asserts,  that  he  superintended  the  delivery  of  one  of  twelve 
pounds  and  three-quarters ;  and  M.  Merriman,  one  weighing  fourteen 
pounds;  Richard  Crofts,  another  of  fifteen  pounds;  lastly,  Mr.  J.  D.  Owens, 
a  surgeon  at  Haymoor,  near  Ludlow,  has  seen  a  still-born  infant  that 
weighed  seventeen  pounds  twelve  ounces,  and  had  the  following  dimensions- 

Occipitofrontal  diameter,  .  .  7£  inches. 

OccipitO'-n.ental,  "  .....  8J       " 

Bi-parietal  "  .....         6         " 

Total  length,  ......  24 

In  the  month  of  May,  1849,  I  was  called  in  consultation  by  Dr.  Riem- 
bault  in  a  case  of  shoulder  presentation.  Several  attempts  at  version  had 
been  made  by  himself  and  another  physician,  and  it  was  with  the  greatest 
difficulty  that  I  succeeded  in  accomplishing  it.  The  child,  which  was  born 
dead,  appeared  to  me  a  very  large  one,  and  I  estimated  its  weight  at  from 
ten  to  twelve  pounds.  After  my  departure,  M.  Riembault,  who,  like  myself, 
had  been  struck  with  its  size,  weighed  it  carefully,  once  with  a  steelyard, 
and  twice  in  different  balances,  and  ascertained  its  weight,  by  the  three 
trials,  to  be  eighteen  pounds.  Its  extreme  length  was  two  feet  one  and  a 
half  inches,  the  bi-acromial  diameter  nine  inches,  the  greater  circumference 
of  the  head  sixteen  and  one-eighth  inches,  and  the  lesser  circumference  nine 
inches.  M.  Riembault  has  assured  me  repeatedly,  that  he  could  guarantee 
the  accuracy  of  these  statements,  since  being  himself  astonished  at  the  results 
of  the  measurements,  he  had  taken  the  precaution  to  repeat  them  several 
times. 

The  mother  stated  that  her  last  menstrual  period  occurred  July  12,  1848, 
and  that  she  expected  to  be  confined  about  the  12th  of  April,  1849.  The 
size  of  the  abdomen  had  been  so  great  since  March,  as  to  lead  her  to  suppose 
that  she  was  pregnant  with  twins.  The  first  pains  were  experienced  on  the 
evening  of  the  6th  of  May,  that  is  to  say,  nearly  a  month  later  than  she 
had  anticipated.  Whether  the  pregnancy  had  really  run  over  its  usual 
term,  and  whether  the  extraordinary  size  of  the  child  was  attributable 
thereto,  are  questions  which  it  is  impossible  to  decide. 

On  the  whole,  therefore,  we  may  conclude  that  the  foetal  growth  is  rapid 
for  the  first  three  months,  then  slackens  off  about  the  middle  of  pregnancy, 
and  again  becomes  greatly  accelerated  during  the  last  three  months. 

Chaussier  has  given  the  following  as  the  proportions  exhibited  by  the 


OF    THE    FCETUS.  217 

different  parts  of  the  foetus  at  birth  (taken  from  a  chiil  nineteen  and  a  half 

inches  long),  namely: 

From  the  top  of  the  head  to  the  pubis, 12J  inches. 

•'     the  pubis  to  the  feet,     ...•••••'* 
"     the  clavicle  to  the  bottom  of  the  sternum,    .         .         .         .2 
"     the  latter  to  the  pubis, "? 

With  regard  to  the  transverse  measurement,  he  found  as  follows :  — 

From  the  top  of  one  shoulder  to  the  other  (bis-acromial  or  trans- 
verse diameter  of  the  thorax) 4I  inches. 

From  the  sternum  to  the  spine  (antero-posterior  diameter),  .  3| 

"     ilium  to  ilium  (transverse  diameter  of  the  pelvis),       .         .  3 

"     one  femoral  tuberosity  to  the  other, H 

We  shall  examine  hereafter  the  dimensions  of  the  head. 

Fortunately,  these  diameters  are  reducible;  thus,  the  bis-acromial  in  par- 
ticular, which  presents  four  and  three-quarter  inches,  may  be  reduced  to 
three  and  three-quarter  inches,  by  compression. 

ARTICLE    II. 

HEAD   OF   THE   FCETUS  AT   TERM. 

The  head  of  the  foetus  merits  the  particular  attention  of  the  accoucheur, 
as  being  really  the  most  voluminous  and  least,  compressible  part  of  the 
child.  It  is,  therefore,  highly  important  to  ascertain  whether  its  several 
diameters  are  proportional  to  those  we  have  heretofore  studied  in  the  pelvis. 
The  head  is  likewise,  in  the  majority  of  cases,  the  part  which  presents  dur- 
ing labor;  consequently,  it  is  very  necessary  that  we  should  be  fully 
acquainted  with  all  its  characters,  in  order  to  recognize  them  at  this  period. 

The  foetal  head,  considered  as  a  whole,  is  ovoidal  in  form,  the  larger 
extremity  being  posterior,  and  the  smaller  anterior ;  as,  in  the  adult,  it  is 
composed  of  the  cranium  and  face ;  but  as  the  latter  does  not  claim  a  par- 
ticular notice,  we  refer,  for  a  knowledge  of  its  different  parts,  to  the  works 
on  anatomy.     Several  bones  enter  into  the  formation  of  the  cranium  ;  they 

are  — 

The  frontal.—  A  symmetrical  bone,  forming  the  forehead,  as  well  as  the 
superior-anterior  part  of  the  face.  It  is  divided  in  the  foetus  into  two  por- 
tions. 

The  two  parietal.—  One  upon  the  right,  the  other  on  the  left  side,  meet- 
ing at  the  median  line;  they  are  situated  upon  the  superior  lateral  parts  of 
the  head,  and  concur  to  form  the  vault  of  the  cranium. 

The  occipital.  —  A  symmetrical  bone,  constituting  the  posterior  part  of 
the  skull,  as  also  a  portion  of  its  base. 

The  temporal.  —  Two  bones  placed,  one  on  the  right,  and  the  other  on  the 
left  side,  below  and  beneath  the  parietal,  completing  the  lateral  portions  of 
the  cranium  and  contributing  to  the  formation  of  its  base;  lastly,  the 
sphenoid  and  the  ethmoid,  which  belong  exclusively  to  the  base.  These 
bones  are  not  united  to  each  other  at  birth  by  serrated  articulations,  as  they 
are  in  the  adult  {immovable  synarthrosis),  but  are  separated,  those  of  the 
vault  especially,  by  membranous  intervals,  of  greater  or  loss  extent,  accord- 


218  PREGNANCY. 

ing  to  the  degree  of  ossification.     The  intervals  have  received  the  name  of 
futures,  or  fontanelles. 

This  arrangement  of  the  vault  of  the  cranium  have  several  advantages 
It  facilitates  the  development  of  the  brain,  and  what  is  hardly  less  impor- 
tant in  the  view  of  the  accoucheur,  it  allows  of  a  certain  reduction  of  the 
diameters  of  the  head.     When  the  latter  is  compressed  forcibly,  the  mai 
gins  of  the  bones  approach  each  other  and  may  even  overlap. 

The  extent  of  this  overlapping  is  liable  to  be  thought  greater  than  it 
really  is,  for,  as  M.  Malgaigne  remarks,  if  we  examine  the  matter  closely 
we  shall  find  that  the  membrane  interposed  between  the  parietal  bones  ia 
too  firm  to  be  drawn  out,  and  too  narrow  to  permit  a  notable  overriding ; 
and  further,  that  it  usually  maintains  these  two  bones  so  close  together,  that 
the  superior  margin  of  one  laps  over  the  other,  leaving  even  on  the  dried 
skull  a  true  normal  crossing.  Some  of  those  sutures,  or  fontanelles,  are 
highly  important  in  an  obstetrical  sense,  and  we  shall  next  proceed  to  their 
consideration. 

The  Sagittal  Suture.  —  This  great  or  antero-posterior  suture  extends  from 
the  root  of  the  nose  to  the  superior  angle  of  the  occipital  bone;  being 
formed  in  front  by  the  interval  that  divides  the  frontal  bone  into  two 
halves,  and  in  the  middle,  and  posteriorly,  by  that  between  the  parietals. 
At  the  superior  and  internal  angle,  formed  by  the  two  portions  of  the  frontal 
bone,  this  suture  is  joined  at  the  sides  by  the  two  fronto-parietal  or  trans- 
verse (coronal)  sutures,  which  are  formed  by  the  space  existing  betwixt  the 
superior  border  of  the  frontal  and  the  anterior  margin  of  the  parietal  bones, 
and  crossing  the  former  suture  nearly  at  right  angles. 

Having  arrived  at  the  superior  angle  of  the  os  occipitis,  it  seems  to  bifur- 
cate, and  give  rise  to  two  oblique  lateral  sutures  formed  by  the  posterior 
borders  of  the  parietal  bones,  and  the  superior  one  of  the  occipital.  These 
latter  are  called  the  lambdoidal  sutures,  probably  from  their  resemblance  to 
the  Greek  capital  A  (lambda).  Just  at  the  points  where  the  fronto-parietal 
and  the  lambdoid  sutures  join  the  sagittal  one,  two  membranous  spaces, 
much  larger  than  those  just  described,  are  found  to  exist,  which  have 
received  the  name  of  the  fontanelles. 

The  great  or  anterior  fontanelle  is  the  one  formed  by  the  junction  of  the 
two  transverse  sutures  with  the  sagittal.  It  is  also  called,  from  the  fact  of 
its  corresponding  with  the  bregma,  the  bregmatic  fontanelle ;  in  general,  it 
presents  an  extensive  surface,  bounded  by  four  bony  angles,  produced  by  the 
lateral  sutures  leaving  it  nearly  at  right  angles.  It  is  lozenge-shaped,  and 
is  usually  much  more  prolonged  into  the  frontal  than  between  the  parietal 
bones.  Sometimes  even,  according  to  M.  Gerdy,  Jun.,  it  scarcely  ceases 
short  of  the  nose,  the  margins  of  the  coronal  suture  being  parted  through- 
out their  whole  extent  by  an  interval  which  gradually  diminishes  from 
above  downwards,  being  only  about  one  or  two  lines  wide  toward  the  root 
of  the  nose.  It  is  not  at  all  uncommon  to  find  at  the  lower  part  of  this 
suture  a  rounded  or  oval  membranous  space,  varying  from  three  to  seven 
lines  in  its  diameter. 

The  posterior  or  occipital  fontanelle  is  formed  by  the  union  of  the  two 
lambdoid  sutures  with  the  termination  of  the  sagittal  suture;  it  is  smaller 


OF    THE    FCETUS.  219 

than  the  preceding,  and  of  a  triangular  form,  being  bounded  by  three  bonv 
angles.  The  lateral  sutures  leave  it  at  an  acute  angle.  The  bony  angles 
are  generally  found  in  contact,  no  membranous  interval  being  left  between 
them.  Sometimes  the  two  portions  of  the  os  occipitis  are  not  fused  into 
each  other  at  birth,  and  in  such  cases  a  median  suture  exists,  which  sepa 
rates  them,  and  terminates  in  the  posterior  fontanelle.  The  latter  has  then 
a  lozenge  shape,  and  is  subtended  by  four  osseous  angles,  and  can  only  be 
distinguished  from  the  anterior  by  the  obliquity  of  the  lambdoidal  sutures. 
The  opposite  condition  is  observed  at  times,  the  triangular  space  known  as 
the  posterior  fontanelle  not  existing  at  all,  because  the  projecting  angle  of 
the  occiput  then  fits  in  and  fills  up  the  entering  one  formed  by  the  parietal 
bones  ;  still  the  convergence  of  the  three  sutures,  and  the  prominence  of 
the  bony  margins  which  overlap  each  other,  will  aid  the  diagnosis  (Mal- 
gaigne)  ;  for  when  the  head  is  engaged  in  the  excavation,  and  has  become 
strongly  compressed,  the  superior  angle  of  the  occipital  bones  is  completely 
concealed  by  the  internal  or  supero-posterior  angles  of  the  parietals ;  and 
if  the  touch  is  resorted  to  under  such  circumstances,  the  finger  can  only 
recognize  the  position  by  detecting  the  little  hollow  formed  by  the  depressed 
occipital  angle.  Of  course,  particular  attention  mus'  be  given  in  this  case 
to  the  oblique  direction  of  the  lambdoidal  sutures. 

The  not  unfrequent  existence  of  spaces  upon  tne  cranium,  where  the 
ossification  is  less  advanced  than  usual,  is  another  source  of  error.  For 
this  defective  ossification  is  substituted  a  membranous  expansion,  which 
might  be  mistaken  for  a  fontanelle. 

Such  an  error  might  the  more  readily  have  occurred  in  the  four  cases  of 
this  kind  which  I  have  had  an  opportunity  of  observing,  from  the  fact  of 
the  accidental  fontanelle  being  situated  just  in  the  course  of  the  sagittal 
suture,  about  equidistant  from  the  anterior  and  the  posterior  ones ;  and  as 
this  point  is  precisely  where  the  finger  first  falls,  in  practising  the  touch, 
we  might  mistake  it  for  a  fontanelle.  But,  by  a  little  attention,  it  will 
always  be  easy  to  avoid  this  error,  by  ascertaining  that  no  lateral  sutures 
pass  off  from  this  membranous  interval. 

There  yet  remain  some  other  sutures,  and  some  other  fontanelles  on  the 
inferior  lateral  parts  of  the  cranium ;  but  as  they  are  devoid  of  interest  we 
shall  not  describe  them. 

Diameters  of  the  Head.  —  The  term  diameter  has  been  applied  to  certain 
fictitious  lines,  which  traverse  the  head  in  a  determinate  direction.  To 
avoid  over-loading  the  memories  of  students,  we  shall  not  multiply  their 
number  as  some  have  done  ;  but,  following  the  example  of  M.  Velpeau,  shall 
describe  only  seven  at  first,  as  it  will  be  very  easy  to  supply  the  deficiency 
hereafter  in  treating  of  the  mechanism  of  labor. 

Seven  diameters,  then,  may  be  distinguished  for  the  foetal  head,  which  we 
divide,  in  order  to  facilitate  their  study,  into  the  antero-posterior,  the  trans- 
verse, and  the  vertical. 

1st.  The  antero-posterior  diameters  are:  the  occipito-mental.  a  b  (Fig.  70), 
extending  from  the  posterior  fontanelle  to  the  chin  ;  this  is  the  longest  of 
all,  being  five  and  a  quarter  inches.  The  occipito-frontal,  de,  which  extends 
from  the  occipital  protuberance  to  the  frontal  boss  (also  called  the  an  ten*- 


220 


PREGNANCY. 


posterior  diameter) :  it  measures  four  and  a  quarter  to  four  and  a  half 
inches.  The  sub-oecipito-bregmatic,  cf,  extends  from  the  middle  of  the 
space  between  the  foramen  magnum  and  the  occipital  protuberance  (to  the 
anterior  fontanelle —  Transl.),  and  is  three  and  three-quarter  inches. 

2d.  The  transverse  diameters  are  two  in  number:  one,  the  bi-parietal,  a  b 
(Fig.  71),  goes  from  one  parietal  protuberance  to  the  other;  it  is  from  three 
and  a  half  to  three  and  three-quarter  inches  long.     The  other,  the  bi-tem- 


poral,  c  d,  passes  from  the  root  of  the  zygomatic  process  on  one  side  to  the 
same  point  opposite.     It  is  two  and  three-quarters  to  three  inches  long. 

3d.  Lastly,  there  are  two  vertical  diameters:  first,  the  vertical  diameter, 
properly  so  called,  or  the  trachelo-bregmutic,  ig,  traverses  the  head  perpen- 
dicularly, passing  from  the  most  elevated  point  of  the  vertex  to  the  anterior 
part  of  the  occipital  foramen.  It  is  three  and  three-quarter  inches  long. 
Professor  Moreau  points  out  another  diameter,  which  he  calls  the  cervico- 
bregmatic,  ch  (Fig.  70)  ;  this  leaves  the  preceding  somewhat  obliquely,  and 
runs  from  the  anterior  part  of  the  occipital  foramen  to  the  anterior  fonta- 
nelle; it  is  three  and  three-quarter  inches  in  length  ;  the  second,  the  fronto- 
mental,  or  the  facial,  da,  extends  from  the  frontal  boss  to  the  point  of  the 
chin.     This  is  three  inches. 

Circumferences. — A  circumference  has  been  assigned  to  each  of  the  above- 
mentioned  diameters,  since  it  is  very  easy  to  describe  from  the  middle  of 
every  one  of  them,  as  a  centre,  a  circle  whose  radius  is  equal  to  one-half  of 
the  diameter,  and  whose  circumference  shall  pass  through  the  two  extremi- 
ties of  the  latter. 

As  a  matter  of  course,  the  greatest  circumference  of  the  head  corresponds 
with  the  occipito-mental  diameter,  and  passing  at  the  same  time  obliquely 
over  the  sides  of  the  face  and  through  the  extremities  of  the  diameter,  has 
a  nearly  horizontal  direction. 

Most  authors  describe  it  as  dividing  the  head  into  two  equal  lateral 
halves, — a  mode  of  regarding  it,  which,  as  M.  Jacquemier  judiciously 
remarks,  is  devoid  of  meaning  as  applied  to  obstetrical  practice. 

The  occipito-frontal  periphery,  agreeing  with  the  diameter  of  the  same 
name,  runs,  horizontally,  a  little  below  the  extremities  of  the  transverse 
diameter,  and  separates  the  vault  from  the  base.  The  sub-occipito-breg- 
malic  circumference  passes  through  the  extremities  of  both  the  occipito- 
bregmatic  and  the  bi-parietal  diameters,  being  thus  common  to  both. 

The  two  latter  are  the  most  important  of  all,  because  they  successively  come 
into  relation  with  the  parietes  of  the  pelvis  in  the  progress  of  natural  labor. 


OF     THE     FOETUS. 


221 


The  circumferences  belonging  to  the  other  diameters  scarcely  ofFer  any 
interest,  and  we  shall  tnerefore  merely  mention  them  in  passing;  in  number 
they  equal  the  diameters. 

The  fronto-mental  circumference,  however,  should  he  noticed  as  passing 
over  the  forehead,  cheeks,  and  chin :  being  also  called,  on  that  account,  the 
facial  circumference. 

The  diameters  just  described,  although  but  slightly  reducible  in  their 
dimensions,  are  not  absolutely  invariable.  Thus  it  is  only  necessary  to 
witness  a  few  difficult  labors  to  become  satisfied,  that  in  such  cases  the 
head  is  most  frequently  elongated  in  the  direction  of  the  occipito-mental 
diameter,  and  flattened  in  its  transverse  one.  And  we  further  learn,  from 
the  experiments  of  Baudelocque,  that  the  bi-parietal  diameter  (see  art. 
Forceps)  may  be  reduced  one-fourth,  or  one-third  of  an  inch,  by  the  aid  of 
instruments ;  indeed,  we  have  even  known  this  diameter  to  be  diminished 
much  more  than  that  under  the  efforts  of  the  womb  alone,  without  any 
accident  occurring  to  the  child. 

Independently  of  those  variations  in  length  of  the  diameters  of  the  head 
in  individual  cases,  which  it  is  impossible  to  foresee,  there  is  one  which  is 
almost  uniform  for  each  sex,  and  of  importance  to  be  acquainted  with.  The 
head  of  the  male  fcetus  is  generally  larger  than  that  of  the  female;  the 
difference,  according  to  Clark,  being  about  the  one-twenty-eighth  or  the  one- 
thirtieth.  This  difference  exerts  a  notable  influence  upon  the  duration  of 
labor  even  in  well-formed  women,  and  may  consequently  have  an  injurious 
effect  upon  the  health  of  the  mother,  and  upon  both  the  life  and  health  of 
the  foetus. 

Thus  it  is  shown  by  the  researches  of  Dr.  Simpson  :  1.  That  the  majority 
of  the  children  which  die  during  labor  are  males :  the  proportion  of  still- 
born boys  to  still-born  girls  being  as  151  :  100.  2.  That  of  children  born 
living,  there  are  more  boys  than  girls  presenting  some  morbid  condition,  or 
some  lesion  produced  during  labor,  and  consequently  more  likely  to  suc- 
cumb within  the  first  weeks  of  their  existence.  3.  That  of  the  mothers 
who  die  during  labor,  or  in  consequence  of  it,  the  majority  have  given  birth 
to  boys. 

It  will  be  readily  understood  that  the  sex  of  the  child  will  have  a  still 
greater  influence  upon  the  result  of  the  labor  where  the  pelvis  is  slightly 
contracted  ;  and  that  with  the  same  diameters,  the  life  of  a  male  foetus 
would  be  often  compromised  when  a  girl  might  pass  with  little  difficulty  and 
no  danger. 

We  present,  in  the  following  table,  the  diameters  of  the  foetal  head,  as 
also  those  of  the  pelvis,  before  described  ;  hoping  that,  when  thus  collected, 
their  study  will  be  rendered  more  easy:  — 


Diameters  of  the  pelvis. 
(In  inches.) 

Anteroposterior. 

Transverse. 

Oblique. 

Sacro-cotyloid. 

Superior  strait, 
Inferior    strait, 
Excavation, 

4\  to  4J 
4|  io  5J 

5* 
4} 

4|  to  4} 

4  to  4£ 

It              « * 

222  PREGNANCY. 


FCETAL  HEAD. 


1C, 


(Occipito-mental,  .         5J         inches. 

Occipito-frontal,         .         4£ 
Sub-occipito-bregmati 
( Bi-parietal, 
\  Bi-temporal, 
j  Trachelo-bregraatic, 


Transverse 
Vertical 


Fronto-mental, 


3*  to  3£ 

3 

3i  to  3| 

3 


The  fundamental  principles  of  midwifery  are  deduced  from  the  corre- 
spondence between  the  foetal  dimensions  and  those  of  the  pelvis.  It  hap- 
pens, in  fact,  that  the  child  at  term  can  only  clear  the  pelvic  canal  by 
presenting  one  end  of  its  long  diameter  ;  that,  whichever  extremity  this  may 
be,  the  delivery  will  still  remain  impossible  if  the  head  should  present  in 
such  a  manner  as  to  have  its  occipito-mental  diameter  parallel  to  those  at 
the  inferior  strait;  that,  consequently,  the  occiput  must  always  engage 
before  the  chin,  or  vice  versa;  and,  lastly,  that  the  most  favorable  position 
of  the  head  requires  the  latter  to  be  strongly  flexed  upon  the  trunk,  so  that 
its  smallest  diameter  (the  sub-occipito-bregmatic)  shall  be  parallel  to  the 
plane  of  the  strait ;  and  that  to  be  in  its  most  favorable  relation  with  the 
pelvis,  the  occiput  must  correspond  with  one  of  the  extremities  of  an  oblique 
diameter. 

The  articulation  of  the  head  with  the  vertebral  column,  and  the  move- 
ments it  permits,  should  also  be  carefully  studied :  thus,  the  occiput  is  con- 
nected to  the  atlas  by  a  close  union,  which  only  admits  the  motions  of 
flexion  and  extension,  which  in  the  foetus  are  far  more  extensive  than  in  the 
adult;  the  atloido-axoid  articulation,  on  the  contrary,  being  ginglymoid, 
only  permits  a  rotation,  which  is  limited  to  the  fourth  of  a  circle.  Whence 
the  conclusion  is  manifest,  that  whenever  the  head  is  caused  to  rotate — the 
body  being  fixed — great  care  must  be  exercised  not  to  pass  the  limits  indi- 
cated ;  for  generally  the  foetus  would  thereby  suffer  a  mortal  lesion.  We 
say  generally,  not  always,  because  two  cases  cited  by  Prof.  Paul  Dubois 
evidently  prove  that  children  may  not  only  survive  this  accident,  but  even 
seem  to  experience  no  bad  effects  whatever  from  it. 

The  great  laxity  of  the  articular  ligaments  in  the  infant  can  alone  explain 
the  little  danger  attending  an  occurrence  which  would  prove  so  disastrous 
in  the  adult.  Finally,  the  natural  situation  of  the  head  is  such  in  the  new- 
born child,  that  the  chin  descends  much  lower  than  the  occiput,  and  the 
axis  of  the  trunk  traverses  the  cranium  obliquely  from  base  to  summit,  and 
from  before  backwards,  passing  a  little  in  front  of  the  posterior  fontanelle. 


ARTICLE    III. 

POSITION   AND   ATTITUDE   OF   THE    FCETU8. 

The  foetus  lies  curved  on  its  anterior  plane  within  the  bag  formed  by  the 
membranes;  usually,  the  head  is  somewhat  flexed,  the  chin  resting  on  the 
anterior  superior  part  of  the  breast ;  the  neck  is  so  Bhort  that  a  slight  degree 


OF    THE    FCETUS. 


223 


The  usnal  position  of  the  child  in  the  womb. 


of  fltxiun  will,  says  M.  Dubois,  produce  this  effect;  the  feet  are  bent  up  in 

front  of  the  legs — the  latter  strongly  flexed 

on  the  thighs,  and  these  again  are  applied  fio.  72. 

to  the  anterior  surface  of  the  abdomen ;  the 

knees  are  separated  from  each  other,  but 

the  heels  lie  close  together  on  the  back  part 

of  the  thighs  ;  the  arms  are  placed  on  the 

sides  of  the   thorax ;    the   fore-arms   are 

flexed  and  thrown  across  the  sternum,  so 

as  to  receive,  as  it  were,  the  chin  between 

the   hands.     The   foetus,   thus   folded   on 

itself,  constitutes  a  nearly  ovoidal  mass ; 

the  longest  diameter  of  which    is  about 

eleven  inches,  having  its  larger  extremity 

represented  by  the  breech,  which  is  turned 

towards  the  fundus  uteri,  while  the  smaller, 

formed  by  the  head,  is  directed  downwards. 

Now,  it  is  evident  that   this  constrained 

position  could  not  have  been  produced  by 

the  mere  pressure  of  the  uterine  walls  on 

the  child,  since  the  latter  is  in  a  cavity 

much    larger    than   its    whole    volume; 

hence,  it  must  be  referred  to  the  individual  itself. 

The  pendent  position  of  the  head  at  term  is  so  common,  that  we  are 
naturally  led  to  inquire  why  such  should  be  the  case?  Formerly,  it  was 
supposed  that,  after  having  reached  the  uterus,  the  head  occupied  the  fundus 
for  the  first  seven  months  of  gestation,  and  the  pelvic  extremity  its  inferior 
part ;  but  that  towards  the  expiration  of  this  period,  the  foetus  reversed  its 
position ;  the  head  approaching  the  orifice,  and  the  breech  going  above. 

This  was  the  received  doctrine  until  the  arguments  of  Delamotte,  Smellie, 
and  more  especially  of  Baudelocque,  completely  subverted  it ;  and  since 
then,  it  has  been  generally  admitted  that  the  foetus,  suspended,  so  to  speak, 
in  the  amniotic  fluid,  by  the  umbilical  cord,  would  naturally  observe  the 
law  of  gravity:  that  is,  the  head  being  the  heaviest  part  would  descend. 
This  explanation  was  almost  universally  adopted,  when  M.  Dubois,  after 
re-examining  the  question,  proposed  another  theory.  He  urged  the  follow- 
ing objections  (whose  value  we  fully  acknowledge)  against  the  influence  of 
specific  gravity,  to  which  the  great  frequency  of  vertex  presentations  had 
been  so  uniformly  attributed,  viz.:  1.  If  a  child  be  plunged  into  a  con- 
siderable quantity  of  any  liquid,  contained  in  a  bathing-tub,  for  instance,  so 
that  its  descent  will  be  very  slow,  in  order  to  afford  the  head  sufficient  time 
to  exert  its  superiority  in  weight,  we  shall  find  all  parts  of  the  foetus  to 
descend  with  an  equal  rapidity,  and,  consequently,  either  the  back  or  one 
shoulder  will  first  reach  the  bottom  of  the  tub.  This  result,  which  is  con- 
trary to  the  general  belief,  is  more  in  accordance  with  what  is  learned  from 
an  attentive  examination  of  the  foetal  structure  ;  indeed,  when  a  comparison 
is  made,  between  the  volume  of  the  cephalic  and  the  pelvic  halves  of  the 
'cetus,  it  would  naturally  appear  that  their  weight  must  be  nearly  balanced; 


224  PREGNANCY. 

the  cranial  cavity,  it  is  true,  contains  a  well-developed  brain,  but  the  abdo- 
men incloses  the  liver,  which  is  no  less  so,  as  also  the  intestines  and  bladder, 
together  with  the  meconium  and  the  urine  accumulated  therein  during 
pregnancy;  2.  It  is  really  impossible  to  believe  that  the  foetus  is  suspended 
bv  the  cord  alone,  except  during  the  early  stages,  for  even  at  the  third 
month  the  cord  is  longer  than  the  greatest  diameter  of  the  uterine  cavity, 
anil  therefore  its  insertion  near  the  pelvic  extremity  can  in  no  wise  con- 
tribute to  the  more  frequent  presentation  of  the  head ;  3.  Besides,  those  women 
who  maintain  the  horizontal  position  during  gestation  on  account  of  ill 
health,  are  not  the  less  liable  to  exhibit  the  same  phenomenon  ;  4.  If  the 
laws  of  gravity  alone  determined  the  position,  the  head  being  more 
voluminous  relatively  to  the  trunk,  during  the  early  months,  the  fcetus 
Bhould  present,  in  cases  of  abortion,  by  the  cephalic  extremity  still  more 
frequently  than  at  term ;  but  observation  establishes  the  contrary;  5.  Lastly, 
in  animals  the  lowest  part  of  the  organ  does  not  correspond  with  the  neck, 
but  rather  to  the  fundus,  of  the  womb;  nevertheless,  the  fcetus  is  much 
oftener  delivered  by  the  head  than  the  pelvic  extremity. 

After  having  tried  to  combat  the  generally  received  opinion  by  the  objec- 
tions just  given,  M.  Dubois  endeavors  to  prove  that  the  vertex  presentation 

is  a  consequence  of  the  instinctive  will  of  the  fcetus  itself. The 

child,  in  i<-»  mother's  Avomb,  has  the  faculties  of  perception  and  motion ;  for 
the  regular  and  nearly  constant  succession  of  the  perception  of  impressions, 
and  the  movements  wdiich  follow,  sufficiently  indicate  the  same  connection 
in  the  foetus,  between  these  two  functions,  that  should  exist  after  birth. 

Now,  the  object  of  these  foetal  movements  are  partly  certain,  partly  pre- 
sumptive ;  consequently,  they  may  be  regarded  as  really  instinctive  deter- 
minations ;  again,  it  is  in  consequence  of  such  a  determination  that  the 
head  in  the  mammalia  is  usually  found  at  that  part  of  the  uterus  nearest  to 
the  pelvic  outlet. 

We  frankly  confess  that  M.  Dubois  seems  to  us  more  skilful  in  destroying 
than  in  building  up ;  and  though  the  reasons  by  which  he  combats  the 
doctrine  hitherto  received  appear  very  strong,  yet  those  whereon  he  founds 
his  opinion  are  not  fully  convincing.  He  is  entitled  to  credit,  however,  for 
having  sought,  in  a  higher  order  of  ideas,  the  explanation  of  a  singular  fact, 
which  does  not  seem,  in  the  present  state  of  our  science,  capable  of  elucida- 
tion by  the  material  reasons  heretofore  given. 

If  we  might  be  permitted  to  hazard  an  opinion,  after  so  many  others,  we 
should  unhesitatingly  say  they  have  erred  by  seeking  only  in  the  fcetus,  its 
form  and  structure,  for  the  cause  of  the  various  positions  which  it  assumes 
in  the  uterine  cavity. 

Already  have  several  authors  endeavored  to  account  for  the  rarity  of 
trunk  presentations,  by  the  vertical,  or  the  nearly  vertical  direction  of  the 
long  diameter  of  the  uterus,  which  would  naturally  force  the  greatest  fcetal 
diameter  in  the  same  line:  for  instance,  the  cause  of  trunk  presentations, 
says  Wigand,  must  be  referred  less  to  the  fcetus  itself  than  to  a  change  in 
the  ordinary  elliptic  form  of  the  uterus.  Now,  by  advancing  a  step  further 
in  the  path  they  have  marked  out,  may  we  not  find  a  satisfactory  explana- 
tion of  the  great  frequency  of  vertex  presentations  in  the  form  of  the  uterub, 


OF   THE    FCETUS.  225 

and  especially  in  its  mode  of  development  at  the  different  periods  of  preg- 
nancy? For,  when  we  reflect  that  the  uterus,  being  developed  during  the 
first  six  months  at  the  expense  of  its  fundus,  is  spread  out  superiorly,  but, 
on  the  contrary,  is  much  contracted  below,  does  it  not  become  evident  that 
the  pelvic  extremity,  which,  from  the  folded  condition  of  the  lower  limbs, 
is  much  more  voluminous  than  the  head,  must  naturally  lie  in  the  largest 
cavity,  that  is,  towards  the  fundus ;  and,  consequently,  that  the  cranium 
av ill  descend  to  the  cervix?  There  can  be  no  doubt  that  the  inferior  part 
spreads  out  in  the  last  three  months  nearly  as  much  as  the  fundus ;  but. 
then,  the  foetal  vertical  diameter  is  too  long  to  permit  it  to  traverse  the 
transverse  diameter  of  the  uterus ;  and  hence,  with  some  few  exceptions, 
the  child  is  forcibly  retained  in  the  position  it  first  assumed. 

Finally,  can  we  not  explain  by  this  circumstance  the  position  of  twins,  in 
cases  of  double  pregnancy,  where  it  frequently  happens  that  one  foetus  pre- 
sents by  the  pelvic  extremity,  and  one  by  the  head  ?  In  a  word,  the  child, 
shut  up  in  its  close  sac,  and  constantly  subjected  to  movement,  must  assume, 
not  instinctively  but  mechanically,  such  a  position  as  will  bring  its  largest 
parts  into  correspondence  with  the  most  spacious  portions  of  the  organ. 

ARTICLE    IV. 

FUNCTIONS   OF   THE   FCETUS. 

The  functions  of  the  child,  while  it  remains  in  the  uterine  cavity,  that 
require  our  particular  attention,  are  its  nutrition,  respiration,  and  circulation. 

§  1.  Of  Nutrition. 

Few  questions  in  physiology  have  given  rise  to  more  discussion  than  this 
of  foetal  nutrition.  However,  it  is  universally  admitted  that  the  nutritive 
materials  are  furnished  by  the  mother's  body ;  but  authors  are  not  as 
unanimous  in  regard  to  the  mode  of  their  introduction  into  the  interior  of 
the  product  of  conception.  For  instance,  some  think  that  the  liquids  secreted 
by  the  internal  uterine  surface  transude  through  the  membranes,  so  as  to 
reach  the  amniotic  cavity,  to  be  there  taken  up  by  the  foetus.  Others  regard 
the  maternal  placenta  as  designed  to  supply  the  child  with  nutritive  matter, 
and  find  in  the  umbilical  cord  the  only  means  of  conveying  it. 

It  is  necessary  to  admit  at  the  outset,  that  there  can  be  no  discussion  ol 
the  question  until  after  the  placenta  is  developed,  or  at  least,  until  aftei 
connection  is  established  between  the  mother  and  child  by  means  of  the 
allantois.  Now,  as  nothing  of  the  kind  exists  in  the  early  periods  of  preg- 
nancy, it  must  be  acknowledged  that  during  this  time,  at  least,  the  maternal 
fluids  must  reach  the  foetus  by  endosmosis  through  the  membranes  of  the 
ovum. 

The  nutritive  matters  cannot  all  be  derived  from  the  same  source  at  the 
v;i  rious  periods  of  gestation.  Thus,  when  the  ovule  quits  the  ovarian  vesicle, 
it  carries  with  it  a  portion  of  the  granules  which  formed  the  proligerous 
disk;  and  it  is  probable  that  these  may  subserve  its  nutrition  during  its 
progress  through  the  first  half  of  the  Fallopian  tube.  In  its  passage  through 
the  other  half,  an  albuminous  matter  secreted  by  the  walls  of  the  tube 
15 


226  PREGNANCY. 

envelops  the  ovule,  and  probably  also  penetrates  through  the  vitelline 
membrane. 

Arrived  in  the  uterine  cavity,  the  ovule  comes  in  contact,  at  all  points, 
with  the  mucous  membrane  of  the  uterus.  The  villi  of  the  chorion  undergo 
a  considerable  development,  and  until  the  placenta  is  formed,  are  all  capable 
of  imbibing  the  fluids  secreted  by  the  internal  surface  of  the  organ.  As  the 
canal  with  which  each  is  provided  opens  into  the  cavity  of  the  chorion,  they 
are  wonderfully  adapted  to  this  purpose;  and  notwithstanding  the  closure 
of  their  extremities,  the  uterine  secretions  pass  by  endosmosis  through  their 
thin  walls ;  like  the  roots  of  a  tree,  they  serve  to  convey  the  nutritive  fluids 
into  the  space  separating  the  chorion  from  the  amnion.  From  thence,  the 
nutritive  juices  transude  through  the  walls  of  the  amnion  into  its  cavity. 
A  certain  portion  of  them  is  conveyed  into  the  body  of  the  foetus  through 
the  canal  of  the  umbilical  vesicle. 

But  as  soon  as  the  vascular  connections,  which,  as  we  have  learned,  are 
established  between  the  maternal  and  foetal  placentas,  begin  to  be  formed, 
the  non-placental  villi  of  the  chorion  tend  gradually  to  waste  away  ;  the 
development  of  the  amnios  obliterates  the  cavity  which  separated  it  from 
the  2horion,  and  along  with  it  also  disappear  the  vitriform  body  and  the 
umbilical  vesicle.  It  now  becomes  a  question,  whether  the  nutritive  matters 
supplied  by  the  mother  can  penetrate  into  the  amniotic  cavity  through  the 
two  membranes  of  the  ovum,  without  collecting  to  an  appreciable  amount 
during  the  passage?  Or,  on  the  other  hand,  are  they  absorbed  by  the 
vascular  radicles  of  the  fcetal  placenta,  and  introduced  into  the  body  of  the 
embryo  by  means  of  the  umbilical  cord? 

The  partisans  of  the  former  opinion  have  endeavored  to  prove:  1,  that 
'he  amniotic  fluid  is  derived  from  the  mother;  2,  that  it  contains  nutritive 
matter ;  3,  that  it  may  enter  the  embryo  in  several  ways. 

a.  It  is  almost  certain  that  the  fluid  is  supplied  by  the  mother,  for  it  is 
the  more  abundant  as  the  child  is  less  developed,  and  its  quantity  diminishes 
relatively  to  the  foetus,  in  proportion  to  the  advancement  of  gestation. 
Now,  the  contrary  should  be  true,  were  it  a  product  of  the  foetus  itself. 
Besides,  foreign  matters  introduced  into  the  stomach  of  the  mother,  or 
injected  into  her  veins,  have  been  discovered  in  the  amniotic  cavity.  It  is 
also  true,  that  they  have  nearly  always  been  found  at  the  same  time  in  the 
blood  of  the  embryo  and  in  the  placenta.  So  that,  strictly  speaking,  it  is 
difficult  to  say  into  what  part  they  were  first  distributed.  Very  dissimilar 
observations  having  reference  to  this  subject  are  on  record.  Thus,  for 
example,  in  the  case  of  an  embryo  of  five  months,  the  mother  of  which  had 
been  poisoned  by  sulphuric  acid,  Otto  found  that  wherever  the  skin  had 
come  in  contact  with  the  amniotic  fluid,  it  was  of  a  reddish-brown  color. 
and  as  hard  as  parchment.  On  the  other  hand,  in  the  case  of  a  woman 
four  months  pregnant,  who  had  been  poisoned  by  arsenic,  MM.  Mareska 
and  Lados  found,  by  analysis,  traces  of  the  poison  in  the  body  of  the  foetus, 
in  the  uterus,  and  in  the  placenta,  whilst  it  could  not  be  detected  in  the  waters 
of  the  amnion.  Mayer,  however,  injected  cyanide  of  potassium  into  the. 
trachea  of  a  rabbit,  and  afterwards  discovered  it  in  the  amniotic  fluid,  1hc 
placer, ta,  and  the  organs  of  the  foetus. 


OF     THE     FCETUS. 


227 


B.  The  amniotic  fluid  must  be  nutritive,  for  it  contains  albumen,  osmazome, 
and* some  salts;  in  fact,  young  calves  have  been  sustained  two  weeks  on  fresh 
amniotic  liquor.  Finally,  the  quantity  of  this  fluid,  and  more  especially 
that  of  the  animal  and  nutritive  substances  found  in  it,  is  much  diminished 
towards  the  end  of  pregnancy. 

c.  Supposing  it  to  be  furnished  by  the  mother,  and  to  possess  nutritive 
properties,  it  remains  to  be  shown  how  it  is  enabled  to  enter  the  body  of 
the  foetus.  There  are  numerous  hypotheses  in  reference  to  this  point. 
The  liquor  amnii  may  reach  the  body  of  the  foetus  in  various  ways. 
1st.  By  cutaneous  absorption.  When  the  umbilical  vesicle  ceases  to  fur- 
nish nourishment  to  the  embryo,  the  skin  becomes  developed,  and,  very 
probably,  absorbs  the  surrounding  amniotic  liquid  ;  it  is  even  possible  that 
the  lymphatic  vessels,  which  are  highly  developed  in  the  foetus,  are  formed 
as  a  consequence  of  this  absorption,  just  as  blood-vessels  are  called  into 
existeuce  by  the  circulation.  , 

Brugmans  proved  this  absorption  by  an  experiment :  thus,  after  having 
extracted  several  living  embryos  of  animals  from  the  waters  of  the  amnios, 
he  noticed  that  the  cutaneous  lymphatics  were  filled,  and  that  those  of  the 
intestines  were  not  so;  then  plunging  the  limbs,  previously  tied,  into  this 
liquid,  he  found,  after  the  lapse  of  some  time,  the  lymphatics  below  the 
ligature  were  filled  with  lymph. 

The  epidermis  is  so  excessively  thin,  that  it  can  offer  no  obstacle  to  the 
imbibition,  and  the  liquor  amnii  itself  contains  a  large  proportion  of  water. 
Again  the  sebaceous  matter  which  covers  the  foetus  at  birth,  only  becomes 
manifest  at  an  advanced  stage  of  pregnancy ;  and,  lastly,  this  absorption 
has  been  directly  proved  in  animals  both  by  experiments  and  dissection. 

2d.  By  the  intestinal  canal.  Though  the  cutaneous  absorption  may  suffice 
for  the  nutrition  of  the  embryo,  as  is  sufficiently  proved  by  the  birth  of 
monsters  and  anencephalous  foetuses  with  closed  mouths,  nevertheless,  it  is 
highly  probable  that  the  child  makes  some  efforts  at  deglutition,  at  least 
towards  the  termination  of  pregnancy,  thereby  determining  the  introduction 
of  fluids  into  the  intestinal  canal.  Thus,  embryos  may  occasionally  be 
observed  executing  motions  of  respiration  with  their  jaws,  during  which  the 
waters  would  necessarily  be  swallowed ;  indeed,  in  ova,  that  have  been 
frozen  after  their  extraction  from  the  cow,  an  uninterrupted  band  of  ice  has 
been  found  extending  from  the  mouth  to  the  stomach.  And  when  the  me- 
conium is  mixed  with  the  amniotic  liquid,  it  is  sometimes  detected  in  the 
throat,  pharynx,  and  stomach.  Lastly,  hair  is  occasionally  found  there, 
which  could  only  happen  as  a  result  of  deglutition. 

Besides  these"  two  modes  of  absorption,  by  the  skin  and  the  intestinal 
mucous  membrane,  some  physiologists  have  supposed  this  fluid  might  be 
taken  up  in  other  ways:  thus,  according  to  some,  the  mammary  glands  are 
provided  with  conduits  that  act  the  part  of  lymphatics,  absorbing  the 
waters,  and  carrying  them  to  the  thymus  gland,  to  be  there  elaborated. 
Others  suppose  that  the  liquor  amnii  may  enter  the  trachea  and  bronchia, 
and  there  undergo  some  modification  which  may  render  it  suitable  for  nutri- 
tion. Lastly,  Lobstein  seems  to  think  it  might  possibly  enter  through  the 
genital  organs.     But  all  these  opinions  are  merely  hypothetical. 


228  PREGNANCY. 

With  all  deference  to  their  ingenuity,  these  hypotheses  are  still  far  from 
being  satisfactory.  The  introduction  of  the  liquor  amnii  into  the  intestinal 
canal  as  a  regular  and  normal  occurrence,  is  by  no  means  proved  by  the 
facts  cited  in  its  support.  It  is,  indeed,  more  than  probable,  that  the  move- 
ments of  deglution  which  the  child  has  been  seen  to  make,  were  really  respi- 
ratory efforts  determined  by  the  suspension  of  the  placental  respiration ; 
also  that  the  icicles,  the  hairs,  and  the  meconium,  found  in  the  stomach, 
had  entered  it  but  a  short  time  before  the  death  of  the  child  ;  in  short, 
where  the  antecedent  death  of  the  mother,  the  compression  of  the  cord,  or 
the  separation  of  the  placenta  had  begun  to  produce  asphyxia. 

Supposing  the  cutaneous  absorption  of  the  liquor  amnii  to  be  proved  by 
the  experiment  of  Brugmans,  it  would  still  seem  unequal  to  the  develop- 
ment of  the  foetus,  which  must  have  some  additional  source  of  nutrition. 

Looking  beyond  the  membranes,  there  evidently  can  be  no  other  source 
of  supply  than  the  maternal  placenta,  and,  in  fact,  many  modern  authors 
regard  the  placental  circulation  as  the  principal  agent  in  the  nutrition  of 
the  fcetus.  It  is  unnecessary  to  suppose  a  direct  communication  between 
the  maternal  and  foetal  vessels,  in  order  to  understand  how  that,  by  means 
of  the  extensive  contact  existing  between  the  vascular  apparatus  of  the  two 
placentas,  a  transudation  may  take  place  of  the  more  fluid  parts  of  the 
maternal  blood,  which  are  absorbed  and  mingled  with  the  foetal  blood  ;  also 
that  this  transuded  fluid  being  charged  with  oxygen  is  subservient  to  the 
hsematosis  of  the  foetal  blood,  at  the  same  time  that  it  supplies  it  with  nutri- 
tive material.  (Van  Huevel.)  It  may,  perhaps,  be  allowed,  that  all  of 
the  villi  of  the  chorion,  in  the  midst  of  which  the  placenta  is  developed, 
may  not  be  applied  to  the  formation  of  the  radicles  of  the  umbilical  vessels, 
but  that  some  of  them  may  continue  to  exercise  their  primitive  functions, 
and  still  absorb  the  fluids  secreted  by  the  utricular  glands  of  the  utero-epi- 
chorial  mucous  membrane. 

What  we  have  already  said  regarding  the  structure  of  the  chorial  villi 
of  the  placenta  lends  countenance  to  this  supposition ;  for  we  have  seen 
(Fig.  68),  that  beside  the  vascular  villi,  some  are  found  to  be  solid,  and 
destitute  of  any  ramification  of  the  umbilical  vessels,  although  still  adher- 
ing by  their  pedicle,  and  communicating  with  a  larger  branch  of  the  villus. 
This  fact  seems,  indeed,  to  have  been  anticipated  by  some  authors :  thus, 
although  Eschricht  regarded  the  placenta  proper  as  being  in  reality  the 
respiratory  organ  of  the  fcetus,  he  supposed  that  the  utricular  glands  of  the 
womb  secrete  a  fluid  designed  for  the  nourishment  of  the  embryo,  which 
fluid  is  taken  up  by  other  branches  of  the  umbilical  vessels  than  those  by 
which  the  placental  respiration  is  effected;  MM.  Prevost  and  Moris  also 
regard  the  placenta  as  the  organ  in  which  the  absorption  of  the  plastic  mat- 
ters supplied  by  the  mother  is  accomplished  by  the  vessels  of  the  fcetus. 
According  to  them,  this  fluid,  which  is  deposited  upon  the  internal  surface 
of  the  womb,  is  taken  up  by  the  vessels  of  the  cotyledons.  Thus,  in  the 
ruminantia,  if  the  ovum  with  its  cotyledons  be  extracted  from  the  womb 
towards  the  end  of  gestation,  by  which,  consequently,  the  foetal  and  mater- 
nal placentas  are  separated  from  each  other,  the  separation  being  easily 
effected   without    laceration,  a   whitish   fluid    is  discovered    in  the  uterine 


OF     THE     F(ETUS.  229 


caruncles,  and  a  similar  one  can  be  expressed  from  the  vascular  brushes  of  the 
cotyledons.  However  this  may  be,  it  is  very  probable  that  the  nutritive 
fluids  reach  the  fetus  through  the  umbilical  vessels  properly  so  called. 

When  mixed  with  the  foetal  blood,  the  nutritive  elements  supplied  by  the 
mother  are,  like  the  chyle  in  the  adult,  devoted  to  the  development  of  the 
organs.  Lee  supposes,  however,  that  they  undergo  certain  changes,  first  m 
the  liver  and  afterward  in  the  intestine.  When  thus  brought  by  the  umbi- 
lical vein  into  the  large  liver  of  the  foetus,  these  elements  experience  changes 
which  result  in  the  formation  of  a  new  albuminous  and  nutritive  compound 
which  is  poured  along  with  the  bile  into  the  duodenum;  there  the  mixture 
is  separated  into  a  recrementitial  part,  which  is  taken  up  by  the  absorbents, 
as  in  the  adult,  and  an  excrementitial  part,  charged  with  carbon,  which 
forms  the  meconium. 

In  fine  until  the  placenta  is  formed,  the  nutritive  elements  reach  the 
interior  of  the  ovum  by  means  of  endosmosis  ;  at  a  later  period  the  growth 
of  the  fcetus  is  maintained  by  an  absorption  through  the  skin  of  some  of 
the  nutritive  matters  contained  in  the  liquor  amnii,  and  by  the  assimilation 
of  those  which  the  radicles  of  the  umbilical  vessels  take  up  in  the  placenta, 
rit  should  be  added,  in  reference  to  this  subject,  that  in  the  foetus,  as  well  as  in 
the  adult,  glucogenesis  is  one  of  the  essential  conditions  of  nutrition.  After  a 
fruitless  search  for  glucogenous  matter  in  the  foetal  liver,  M.  Bernard  found  it  in 
the  placentas  of  the  mammalia,  being  especially  present  in  the  epithelial  layer  ot 
the  intei-utero-placental  mucous  membrane.  To  the  already  determined  functions 
of  the  placenta  we  have,  therefore,  to  add  this  of  glucogenesis,  which  would  seem 
to  replace  the  hepatic  function  in  this  respect  during  the  earlier  periods  of  e.nbry- 

onic  life.  ,  .  ,        , 

In  the  ruminantia,  the  glucogenic  matter  having  become  separated  from  the  pla- 
centa is  found  spread  over  the  free  surface  of  the  amnion  and  chorion  in  the  form 
of  epithelium-like  scales,  which  are  easily  seen,  but  which  have  not  hitherto  been 
understood.  (CI.  Bernard.  Lecons  de  Physiologic  1855.— Memoires  de  la  Sociele  de 
Biologie,  I860.)] 
§  2.  Respiration. 

Does  the  fcetus  respire  in  the  amniotic  cavity? 

If  something  analogous  to  respiration  in  the  adult  be  sought  for  in  the 
functions  of  the  foetus,  this  question  will  doubtless  be  answered  negatively; 
because  the  atmospheric  air  having  no  access  to  it  whatever,  the  foetal  blood 
could  not  possibly  obtain  any  elements  from  it.  But  does  it,  therefore, 
follow  that  the  sanguineous  fluid  will  experience  no  similar  modification  at 
any  part  of  the  circuit?  Most  physiologists  think  otherwise,  and  I  share 
their  opinion.  ,  , 

According  to  some, the  liquor  amnii  is  the  modifying  agenl  for  the  blood, 
and  Beclard  supposes  thai  the  lungs  are  the  seal  of  such  changes,  the 
amniotic  liquid  reaching  them  through  the  air-passages.  Agreeably  to  M. 
Geoffroy  St.  Hilaire,  the  whole  surface  of  the  child's  bu.lv  absorbs  air,  or  a 

vivifyin as,  like  insects,  by  a  species  of  air-tubes,  or  by  minute  fissures 

whirl,  exist  on  the  lateral  pari,  of  the  neck  in  young  embryos.  Che *  resem- 
blance between  those  fissures  and  the  branchial  apparatus  m  the  fish  has 
given  rise  to  the  belief  of  an  analogous  function;  hence,  they  arc  called 
the  branchial  fissure*. 


2H0  PREGXAXCY. 

But,  says  BischofF,  in  the  mammalia  and  man,  these  arcs  never  have  ai 
organization  justifying  in  the  least  the  supposition  of  tneir  being  intended 
for  respiration  ;  they  never  have  internal  nor  external  branches ;  nor  da 
we  ever  see,  as  in  the  branchia,  vessels  distributed  either  on  their  surface  or 
in  their  interior. 

Latterly,  M.  Serres  has  attempted  anew  to  explain  how  respiration  may 
take  place  in  the  embryo  before  the  placenta  is  fully  formed.  He  says  the 
breathing  apparatus  of  the  human  ovule  consists  of  the  chorion,  the  two 
layers  of  the  decidua,  the  liquid  contained  between  the  latter,  and  of  a 
particular  class  of  villi,  called  by  him  the  branchial,  which,  after  having 
traversed  the  reflected  decidua,  come  into  contact  with  this  liquid.  On  the 
one  hand,  the  reflected  decidua  is  perforated  by  multitudes  of  foramina, 
which  may  be  aptly  compared  to  those  on  the  cribriform  plate  of  the 
ethmoid  bone;  and  on  the  other,  the  chorial  villosities,  the  branchial  villi, 
entering  the  substance  of  this  membrane,  lodge  in  those  openings,  and  thus 
are  brought  into  immediate  apposition  with  the  liquid.  M.  Serres  believes 
that  this  arrangement  presents  all  the  conditions  of  a  branchial  respiratory 
apparatus ;  but  this  mode  of  respiration  only  lasts  during  the  first  fifteen  or 
twenty  days  of  the  intra-uterine  life;  because,  as  the  embryo  is  developed 
and  grows,  one  part  of  the  villi  of  the  chorion  is  transformed  into  the 
placenta,  and  the  foetal  respiration  in  the  uterus  then  commences  the  second 
time,  as  the  placental  respiration.  Then  the  branchial  function  decreases, 
the  apparatus  atrophies  and  disappears:  at  first,  the  branchial  villi  of  the 
chorion  wither  away;  the  cavity  of  the  decidua  is  contracted;  the  liquid 
diminishes ;  and,  finally,  the  two  lamina?  of  the  decidua  being  brought  into 
apposition,  unite  and  become  confounded  with  each  other. 

This  hypothesis,  though  ingenious,  is  evidently  based  upon  badly  observed 
facts,  and  cannot  be  sustained  after  the  description  of  the  decidua  which  we 
have  given. 

After  the  allantois  is  developed,  the  villi  of  the  chorion,  which  have  then 
become  vascular,  are  in  immediate  contact  with  the  hypertrophied  vessels 
of  the  mucous  membrane,  and  from  this  moment  the  foetal  blood  derives 
cherefrom  the  elements  necessary  to  hamiatosis.  In  proportion  as  the  con- 
tact becomes  more  intimate  and  extensive,  the  organization  of  the  placenta 
progresses,  and  soon  forms  a  compact  mass,  which  is  the  seat  of  the  placental 
respiration. 

In  fact,  this  body  is  formed  throughout  in  such  a  manner  as  to  establish 
the  greatest  possible  approximation  between  the  maternal  blood  and  that 
of  the  embryo;  and  this  mediate  union,  in  which  the  two  liquids  are 
separated  by  fixed  membranes,  establishes  between  the  foetal  and  the 
maternal  blood  the  same  relation  that  is  known  to  exist  in  the  lungs  of  the 
adult,  betwixt  the  venous  blood  and  tin;  atmospheric  air:  thus,  in  the  pul- 
monary organs,  the  blood  is  brought  within  the  influence  of  the  inspired 
air ;  true,  there  is  none  of  the  latter  in  the  after-birth,  but  the  maternal 
vessels  are  found  there  in  great  abundance,  whose  exceedingly  delicate 
walls  remain  for  a  long  time  in  contact  with  the  umbilical  radicles,  the 
parietes  of  which  are  also  thin  and  transparent. 

Therefore,  if  nothing  but  thin,  transparent  membranes  divide  the  fetal 


OF    THE    FCETUS.  *31 

olood  from  that  of  its  mother,  is  it  not  possible  for  the  fir*  to  communicate 
somp  of  its  elements  to  the  second?  for,  does  not  the  air  act  thr  aigh  the 
walls  of  the   pulmonary  vessels  of  the   blood    contained   therein?     And 
further  is  not  such  a  modification  of  the  fetal  blood  in  the  placenta  suffi- 
ciently Wed:  1st.  By  the  early  death  of  the  child,  when  the  umbilical 
cord  becomes  flattened  from  compression,  and  its  circulation  thereby  arrested 
2d    By  the  pathological  phenomena  of  asphyxia,  which  are  always  revealed 
by'  the  autopsy  in  such  cases.     3d.    By  the   antagonism   known  to  exist 
between  the  after-birth  and  the  lungs;  in  fact,  the  new-born  infant  may 
dispense  with  the  pulmonary  respiration,  so  long  as  its  connection  with  the 
placenta  remains  uninterrupted,  and  this  communication  may  be  broken 
without  danger  as  soon  as  it  respires  through  the  lungs  ;  if  it  breathe  freely, 
the  blood  no  longer  passes  along  the  cord,  and,  should  respiration  cease,  it 
shortly  flows  anew.     And  4th.  By  the  difference  in  the  blood  circulating 
in  the  umbilical  vein,  and  that  in  the  arteries,  — a  distinction  not  verj 
manifest  upon  simple  inspection,  but  which  has  been  detected  by  physica. 
and  chemical  experiments.     Now,  in  the  adult  pulmonary  respiration,  the 
blood  not  only  absorbs  a  certain  portion  of  oxygen  from  the  air,  but  it  also 
gives  off"  some  carbonic  acid.     Thus  far,  we  have  only  learned  that  the  fetal 
blood  derives  from  the  placenta  a  vivifying  principle;  but  we  have  not 
observed  the  separation  of  those  materials  from  it,  which  may  be  unsuited 
to  the  nutrition  of  the  child.     We  may  state,  however,  that  most  physiolo- 
gists believe  the  liver  is  destined  to  the  performance  of  this  last  elaboration, 
and  to  the  removal  of  its  superabundant  carbon  and  hydrogen,  which  latter 
are  employed  in  the  formation  of  the  bile,  and  contribute  to  the  complete 
development  of  the  organ.     We  know,  in  fact,  that  the  growth  of  the  liver 
follows  that  of  the  placenta,  that  both  have  a  perfect  organization  at  the 
same  periods,  that  the  bile  is  a  highly  carbonized  fluid,  and  that  the  liver 
has  a  similar  chemical  composition. 

§  3.  Circulation. 

a  The  fetal  vascular  apparatus  exhibits  certain  anatomical  peculiarities 
that  do  not  exist  in  the  adult,  and  which  must  be  noticed,  in  order  to  render 
the  account  of  the  circulation  comprehensible.  Now,  these  characteristics 
evidently  depend  on  the  absence  of  the  pulmonary  respiration,  for  they  dis- 
appear as  soon  as  it  is  established  ;  thus  : 

1  It  is  well  known  that  the  heart  in  the  adult  is  composed  of  four  cavi- 
ties' namely,  a  right  and  left  auricle,  and  a  right  and  left  ventricle,  each 
auricle  communicating  freely  with  the  corresponding  ventricle,  but  not  with 
its  fellow,  being  separated  from  it  by  a  complete  partition.  In  the  fetua 
this  dividing  wall  exhibits  an  opening,  called  the  foramen  of  Botal,  which 
becomes  smaller  as  the  pregnancy  advances,  and  is  wholly  obliterated  atter 
birth,  in  consequence  of  a  valve  being  developed  on  its  interior  margin 
which  gradually  diminishes  the  freedom  of  the  passage,  and  is  large  enough 
at  term  to  obliterate  the  orifice  entirely. 

2  In  the  adult,  the  pulmonary  artery  divides  into  two  large  branches, 
one  for  each  lung :  these  ramify  throughout  its  ultimate  tissue,  distributing 
therein  the  venous  blood  derived  from  the  right  ventricle ;  the  blood  is  next 


282  PREGXANCY. 

taken  up  by  the  radicles  of  the  pulmonary  veins  and  carried  back  by  them 
to  the  left  auricle.  This  vascular  circle  is  interrupted  in  the  foetus,  in  which 
the  tvn  pulmonary  arteries  are  very  small,  although  their  common  trunk 
gives  origin  to  a  voluminous  canal  which  opens  directly  into  the  arcus  aortse, 
and  is  called  the  arterial  canal  or  the  ductus  arteriosus. 

3.  The  abdominal  aorta  bifurcates,  so  as  to  form  the  primitive  iliac 
arteries,  and  each  of  these  again  divides  into  two  branches,  the  hypogastric 
and  the  external  iliac.  In  the  foetus,  the  hypogastric  seems  to  be  continuous 
with  a  large  vascular  trunk  called  the  umbilical  artery,  but  this  is  nearly 
obliterated  in  after-life.  The  two  umbilical  arteries  run  forwards  and 
inwards  along  the  lateral  and  superior  parts  of  the  bladder,  and  soon  curve 
forwards  so  as  to  reach  the  inner  surface  of  the  anterior  abdominal  wall, 
along  which  they  ascend  to  the  umbilicus,  then  pass  along  the  cord,  and 
ultimately  ramify  in  the  placenta. 

4.  Lastly,  the  foetus  further  differs  from  the  adult  in  having  an  umbilical 
vein,  which,  commencing  by  numerous  ramifications  in  the  placental  tissue, 
traverses  the  whole  length  of  the  cord,  and  reaches  the  abdomen  by  passing 
through  the  umbilical  ring;  then,  running  upwards  and  to  the  right  in  the 
substance  of  the  suspensory  ligament  of  the  liver  immediately  behind  the 
peritoneum,  it  gains  the  horizontal  or  umbilical  fissure  of  this  organ  at  its  an- 
terior part,  where  it  gives  off  a  few  branches  that  ramify  in  the  right  and  left 
lobes.  Just  at  the  point  where  the  two  fissures  of  this  viscus  intersect  each 
other,  the  umbilical  vein  becomes  enlarged,  and  then  divides  into  two 
branches  :  the  posterior  of  which,  called  the  venous  canal,  or  ductus  venosus, 
is  a  continuation  of  the  primitive  trunk,  and  goes  sometimes  to  the  vena 
cava  inferior  above  the  diaphragm,  though  at  others  it  joins  one  of  the 
hepatic  veins,  and  the  common  trunk  thus  formed  empties  into  the  vena 
cava ;  the  other  branch  is  much  larger,  and  runs  to  the  right ;  it  leaves  the 
principal  trunk  lower  down  and  more  in  front  than  the  venous  canal ;  then 
it  unites  with  the  vena  portse,  producing  a  canal  whose  diameter  is  double 
its  own.  This  is  called  the  canal  of  reunion,  or  the  confluence  of  the  portal 
and  umbilical  veins.  After  a  short  course,  this  vessel  subdivides  and  rami- 
fies in  the  substance  of  the  liver,  anastomosing  with  the  hepatic  veins,  which 
(as  in  the  adult)  finally  reach  the  vena  cava  a  little  above  the  ductus  venosus. 


EXPLANATION  OF  PLATE  IV. 

THE   FCETAL  CIRCULATION  (Flint). 

Plate  IV.,  which  is  a  diagram  of  tlic  foetal  circulation,  taken  from  Flint's  Physiology, 
ib  sufficiently  plain  to  give  at  a  glance  the  relative  position  of  the  organs  and  the 
peculiar  arrangement  of  vessels  and  valves. 

The  Eustachian  valve,  the  foramen  ovale,  and  the  two  auriculo-ventricular  orifices, 
are  represented  by  dotted  lines. 

The  branches  of  the  uterine  iliac  arteries  which  pass  to  the  placenta,  the  ductus 
venosus,  the  umbilical  vein,  the  Eustachian  valve,  the  foramen  ovale  [foramen  Botal), 
uii't  the  ductus  arteriosus  do  not  exist  in  the  adult. 


Plate  IV. 


b   1  s-.I- 

S     2   ft.s 

i    *      •■ 

t  <4|| 

$>* 

■  >*"     jfHBifti 

s& 

Pulmonary  Art.  ;g^S 

I'll  \ 

^Pulmonary  Art, 

Foramen  Ovale. / 

Left  Auricle. 

—Left  Auric.  -  Vent, 
Opening. 

Eustachian  Valve. (t 

\  *     \ 

Right  Auric.  -  Vent.  Opening. \\ 

5*1 

\~3*    \ 

\\       <** 

\  ^* 

»  V 

\\       % 

Hepatic  Vein.y 

Branches  of  the 
Umbilical  I Tein  > 
to  the  Liver, 


'"••-.  Liver. 


\f 


'^Ductus  Venosut. 


Madder. 


V 


Internal  Iliac  Arteries, 


DIAGRAM  OFTH1.    FCETAL  CIRCULATION. 


..;  Tnm&r'i  Obstetric*. 


OF     THE     FOETUS.  23$ 

b.  Now,  having  acquired  these  anatomical  views,  let  us  see  what  is  the 
course  of  the  blood  in  the  foetus.  A  part  of  this  fluid,  circulating  in  the 
umbilical  vein,  is,  therefore,  discharged  by  the  venous  canal  directly  into 
the  vena  cava ;  another  part  is  distributed  to  the  liver,  where  it  probably 
undergoes,  as  before  stated,  some  purification,  and  thence  is  brought  back 
by  the  hepatic  veins  to  the  vena  cava.  Consequently,  all  the  blood  from 
the  umbilical  vein  reaches  the  vena  cava  inferior  either  directly  or  indirectly. 
The  blood  contained  in  the  latter  is  therefore  a  mixture  of  that  which  returns 
from  the  inferior  extremities  of  the  foetus  and  of  that  poured  into  the  liver 
by  the  vena  portse,  with  the  addition  of  the  portion  contributed  by  the 
umbilical  vein.  This  compound  reaches  the  right  auricle  through  the 
ascending  vena  cava,  where  it  only  mixes  partially  with  the  blood  of  the 
upper  extremities,  which  has  been  brought  back  by  the  descending  vena 
cava ;  because,  in  passing  into  the  auricle,  the  ascending  or  inferior  vena 
cava  is  directed  towards  the  foramen  of  Botal,  and  hence  its  blood  passes 
in  a  great  measure  through  this  opening  into  the  left  auricle,  and  thence 
into  he  left  ventricle.  By  the  contractions  of  this  latter  the  fluid  is  then 
forced  into  the  aorta,  its  impetus  being  broken  against  the  great  curvature 
of  this  artery ;  and  the  blood  then  passes  into  the  vessels  which  arise  from 
the  arch,  and  is  distributed  through  them  to  the  head  and  superior  extremi- 
ties, a  very  small  portion  of  it  only  reaching  the  descending  aorta  and  the 
lower  parts  of  the  body. 

The  blood,  after  having  thus  supplied  the  upper  half  of  the  body,  is  col- 
lected by  the  veins,  which,  by  their  successive  union,  form  the  superior  or 
the  descending  vena  cava ;  the  latter  empties  into  the  right  auricle,  where  a 
email  quantity  of  its  blood  mixes  with  that  brought  by  the  ascending  cava ; 
but  much  the  largest  part  passes  directly  into  the  right  ventricle,  which 
forces  it  into  the  pulmonary  artery. 

This  vessel  sends  but  a  trifling  portion  to  the  lungs ;  the  rest  being  thrust 
into  the  ductus  arteriosus,  which  discharges  its  contents  into  the  aorta :  that 
is  to  say,  the  blood  that  has  contributed  to  the  nutrition  of  the  superior  parts 
of  the  body,  and  has  traversed  the  descending  vena  cava,  the  right  auricle, 
the  right  ventricle,  and  pulmonary  artery,  and  then  has  passed  through  the 
ductus  arteriosus,  finally  mingles  with  the  remnant  of  blood  still  existing  in 
the  descending  aorta.  The  whole  now  descends  to  the  inferior  part  of  the 
latter  vessel,  where  a  small  portion  of  it  is  sent  through  the  arterial  trunk 
to  supply  the  inferior  extremities,  whilst  much  the  largest  quantity  is  driven 
into  the  umbilical  arteries,  and  is  carried  by  them  back  to  the  placenta  : 
where,  after  having  undergone  the  modifications  produced  bj  the  placer,  la  1 
respiration,  it  is  again  taken  up  by  the  radicles  of  the  umbilical  vein  to  once 
more  traverse  the  same  circuit. 

c.  Of  the  Changes  in  the  Circulation  after  Birth. — It  is  difficult  to  explain 
the  cause  of  the  first  inspiration  ;  by  some,  it  has  been  attributed  to  an 
instinctive  movement  of  the  foetus,  from  the  "  besoin  de  respirer"  (necessity 
uf  respiring)  experienced  by  it,  after  a  separation  from  the  placenta ;  but 
these  reasons  are  not  satisfactory  to  me,  for  the  air  is  only  introduced  into 
the  lung  as  a  consequence  of  the  enlargement  of  the  cavity  of  the  chest,  and 
not,  as  some  imagine,  to  fill  a  vacuum  which  never  existed.     Now   this 


234  PREGNANCY. 

expansion  of  the  chest  has  for  its  sole  cause  the  violent,  jerking,  spasmodic 
contraction  of  the  diaphragm,  which  is  always  the  result  of  a  suffering  con- 
dition of  the  foetus,  caused  by  the  suspension  of  the  utero-placental  circula- 
tion, the  sudden  impression  of  cold,  or  the  different  characters  of  the  media 
to  which  the  child  is  successively  and  rapidly  subjected.  Finally,  also,  by 
the  artificial  excitations  (friction  on  the  surface,  irritation  of  the  mucous 
membranes,  &c.)  resorted  to  when  the  infant  is  feeble. 

As  soon  as  the  respiration  becomes  established,  the  sanguineous  current- 
takes  another  direction  ;  because,  on  the  one  hand,  the  fluid  flows  towards 
the  lungs  in  greater  quantity ;  and,  on  the  other,  the  placental  circulation 
is  forcibly  interrupted.  Below,  I  subjoin  the  results  of  the  labors  of  Billard, 
who  has  devoted  particular  attention  to  the  modifications  then  observed  in 
the  organs  of  circulation,  as  they  are  interesting  alike  to  the  accoucheur 
and  the  medical  jurist. 

The  fcetal  openings  are  generally  obliterated  in  the  course  of  a  week  after 
birth,  still,  they  may  remain  patulous  at  that  age;  and,  I  may  add,  that 
either  the  foramen  of  Botal  or  the  arterial  canal  may  continue  pervious  at 
two  or  even  three  weeks,  without  the  child's  experiencing  any  particular 
disadvantage  therefrom  during  after-life. 

The  umbilical  arteries  are  usually  closed  on  the  second  day  ;  even  at 
twenty  four  hours  they  have  already  become  smaller  in  the  vicinity  of  the 
ring,  and  they  are  obliterated  by  the  third  or  fourth  day  as  far  as  their 
junction  with  the  hypogastrics,  by  gradually  changing  into  a  fibrous  cord; 
the  whole  process  being  completed  in  three  weeks. 

The  umbilical  vein  is  never  obliterated  until  after  the  arteries  have  become 
impervious,  and  the  same  is  true  of  the  ductus  venosus ;  however,  both  are 
quite  empty,  and  considerably  contracted  on  the  fourth  day,  and  they  are 
generally  closed  up  by  the  sixth  or  seventh. 

The  arterial  canal  and  the  foramen  of  Botal  are  the  last  to  undergo  this 
process ;  but  they  rarely  persist  beyond  the  eighth  or  ninth  day,  although 
the  foramen  sometimes  remains  open  much  longer,  being  only  effaced  com- 
pletely towards  the  end  of  the  first  year. 

If  the  ductus  arteriosus  and  the  umbilical  arteries  be  examined  during 
the  progress  of  obliteration,  their  parietes  will  be  found  to  grow  gradually 
thicker;  this  hypertrophy  is  particularly  observable  in  the  arteries  near  the 
navel,  as  may  be  easily  verified  by  making  sections  of  them  at  this  point ; 
but  the  thickness  gradually  diminishes  towards  their  origin  from  the  iliacs, 
and  their  canal  is  likewise  obliterated  precisely  in  the  same  order  of  pro- 
gression.  Of  course,  the  contractility  of  its  walls  will  also  contribute  towards 
effecting  the  occlusion. 

The  arterial  canal  undergoes  a  similar  hypertrophy  and  parietal  retrac- 
tion, which  takes  place  in  such  a  manner  that,  whilst  the  absolute  size  of 
the  vessel  does  not  appear  diminished,  its  orifice  is  greatly  contracted, 
resembling  a  pipe  whose  fracture  is  quite  thick,  and  opening  at  its  centre 
of  very  moderate  calibre.  The  obliteration  is  therefore  the  immediate 
result  of  the  retraction  and  concentric  hypertrophy  of  the  walls ;  neverthe- 
less, it  should  not  be  regarded  as  the  primitive  cause,  for  if  the  same 
quantity  (  f  blood  flowed  into  those  vessels,  such  a  retraction  evidently  could 


OF     THE     FOETUS.  235 

not  take  place;  but  from  the  very  first  inspiration,  this  fluid  is  driTen  by 
the  contraction  of  the  right  ventricle  (see  hereafter)  almost  entirely  into  the 
pulmonary  arteries,  scarcely  any  of  it  passing  by  the  ductus  arteriosus; 
and,  on  the  other  hand,  the  very  oblique  angle  at  which  the  umbilical 
arteries  pass  off,  satisfactorily  explains  why  the  blood,  that  flows  into  them 
in  such  great  abundance  when  it  has  no  other  outlet,  no  longer  enters  them 
at  all,  or  at  least  only  very  feebly,  when  the  establishment  of  respiration 
has  completed  the  vascular  circle  of  the  new-born  child. 

But  the  umbilical  vein  and  the  ductus  venosus  are  not  obliterated  in  this 
way,  and  their  walls  exhibit  no  remarkable  increase  of  thickness ;  for,  after 
the  cord  has  been  cut,  these  vessels  receive  no  more  blood,  excepting  in 
those  cases  where  it  regurgitates  from  the  vena  cava,  and  then  the  walls  •fall 
in  and  become  contiguous,  just  like  any  other  canal,  when  the  liquids  that 
habitually  traverse  it  are  cut  off;  nevertheless,  the  umbilical  vein  and  the 
ductus  venosus  retain  their  cavities  free  for  a  long  time,  for  a  large  probe 
may  easily  be  introduced  into  them  ;  but  this  cannot  be  done  in  the  arteries 
nor  in  the  ductus  arteriosus.1 

The  foramen  of  Botal  is  the  last  to  disappear,  although  an  effort  at 
obliteration  may  be  observed  there  sooner  than  in  any  other  of  the  foetal 
openings :  thus,  the  two  auricles  are  nearly  confounded  in  one  in  the  early 
stages  of  intra-uterine  life,  and  the  diminution  of  the  foramen  ovale  only 
begins  to  take  place  about  the  third  month  by  the  development  of  a  semi- 
lunar valve  on  its  inferior  border.  This  valve,  composed  of  a  double  mem- 
branous layer,  containing  fleshy  fibres  in  its  substance,  gradually  rises 
along  the  margins  of  the  opening  towards  the  left  auricle,  by  contracting 
adhesions  with  the  circumference  of  the  foramen,  and  it  ultimately  forms 
the  fundus  of  the  fossa  ovalis,  as  also,  the  little  semilunar  fold  seen  in  the 
auricle.  In  this  way  the  partition  is  completed,  being  merely  perforated 
by  an  oblique  canal  occasionally  found  in  young  subjects,  which  also  dis- 
appears after  a  time.2 

The  following  summary  Avill  enable  the  reader  to  appreciate  the  influence 
of  these  vascular  changes  upon  the  circulation. 

Immediately  after  the  first  inspiration,  and  from  the  sole  fact  of  the  dis- 
tention of  the  pulmonary  cells,  the  branches  of  the  pulmonary  artery, 
ramifying  in  the  mucous  membrane,  and  contributing  to  the  formation  of 
their  walls,  are  suddenly  rendered  permeable  throughout  their  whole  extent, 
and  a  vacuum  is  therefore  produced,  into  which  the  blood  is  sent  from  the 
right  ventricle;  consequently,  from  that  period,  the  route  travelled  by  this 

1  A  case  of  persistence  of  the  umbilical  vein  in  the  adult,  which  communicated  at 
one  extremity  with  the  vena  portse,  and  at  the  other  with  the  crural  vein  through  the 
superficial  abdominal  veins,  is  reported  by  M.  Cruveilhier,  in  the  16th  number  of  his 
Pathological  Anatomy. 

2  According  to  Dr.  Tyler  Smith,  the  expansion  of  the  lungs  produces  a  compression 
of  the  ductus  arteriosus  by  the  left  bronchus,  and  thus  assists  in  its  obliteration.  The 
change  effected  in  the  position  of  the  heart  also  aids  mechanically  the  occlusion  of  the 
foramen  ovale;  and  finally,  the  depression  of  the  liver  by  the  respiratory  act.  closes 
the  umbilical  vein  by  flattening  its  walls.  [The  Lancet,  Sept.,  lsls.|  Nunc  of  these 
assertions  appear  to  us  sufficiently  well  proved,  and  therefore  demand  further  investi- 
gation. 


236  PREGNANCY. 

fluid,  from  the  right  ventricle  to  the  aorta,  is  much  longer  than  heretofore, 
and  the  ductus  arteriosus,  being  thus  emptied,  -will  retract  at  once,  and  have 
its  calibre  very  much  diminished. 

The  right  auricle,  "which  could  scarcely  force  all  the  blood  that  it  received 
from  the  venae  cavse,  through  the  foramen  of  Botal,  now  sends  the  most  of 
it  into  the  right  ventricle. 

Prior  to  birth,  the  left  auricle  only  received  the  blood  by  the  foramen 
ovale,  but  it  is  henceforth  filled  with  that  brought  through  the  four  pul- 
monary veins.  Moreover,  the  relation  that  existed,  in  the  quantity  of  the 
blood  deposited  in  each  auricle,  is  changed  from  that  time ;  for  the  right, 
which  was  distended  beyond  measure,  now  relieves  itself  with  facility,  while 
I  he  left,  that  scarcely  received  any  before,  is  filled  with  the  blood  brought 
by  the  pulmonary  veins ;  so  that  it  would  flow  from  the  left  to  the  right 
auricle,  through  the  foramen  ovale,  if  the  semilunar  partition,  which  acts  as 
a  valve,  did  not  prevent  such  a  movement. 

[$  4.  Innervation. 

Most  of  the  encephalic  functions  remain,  according  to  M.  Jacquemier,  entirely 
dormant  during  intra-uterine  life.  Sensibility,  however,  becomes  highly  developed 
in  the  foetus  at  quite  an  early  period  ;  in  proof  of  which  it  is  only  necessary  to  press 
upon  the  womb  through  the  walls  of  the  abdomen,  when  the  foetus  will  be  found 
to  move  for  the  purpose  of  avoiding  compression. 

A  more  direct  experiment  may  be  made  as  follows.  If  the  abdomen  of  a 
pregnant  rabbit  be  opened,  the  foetus  will  be  visible  through  the  transparent 
walls  of  the  womb,  and  a  foot  may  be  readily  caught  and  compressed  by  a  pair  of 
forceps.  When  this  is  done,  the  foetus  moves  in  such  a  manner  as  to  leave  no 
doubt  that  it  feels  a  certain  degree  of  pain;  for  its  action  could  not  be  regarded  a 
merely  reflex  phenomenon.  Spontaneous  motions  are  caused  by  instinct  or  a  vague 
and  obscure  exercise  of  volition. 

During  intra-uterine  life,  therefore,  and  especially  near  the  end  of  gestation, 
innervation  is  almost  as  perfect  as  in  the  new-born  child. 

The  functions  of  the  foetal  nervous  system  present,  like  those  of  the  adult,  an 
intermittent  action  or  periodicity,  resembling  the  waking  and  sleeping  states. 

When  a  new-born  child  is  asleep,  if  it  be  awakened  and  excited  briskly  several 
times  with  the  tip  of  the  finger,  it  will,  at  the  moment  of  awakening,  almost  always 
make  some  abrupt  motions.  The  same  thing  takes  place,  no  doubt,  during  intra- 
uterine life,  so  that  when  we  try  to  produce  active  movements  by  compressing  the 
uterus,  it  is  probably  aroused  from  the  sleeping  to  the  waking  state,  and  just  then 
the  hand  on  the  abdomen  becomes  conscious  of  the  actions  elicited.] 

§  5.  Secretion. 

As  it  is  not  our  intention  to  treat  of  all  the  various  secretions  which  occur 
in  the  foetus,  we  shall  confine  our  remarks  to  those  of  the  bile,  meconium, 
and  urine. 

1.  Secretion  of  Bile. — The  liver  is  the  most  voluminous  of  all  the  foetal 
organs.  At  three  months  its  texture  Is  3oft  and  pulpy,  not  yet  having  the 
granular  character  visible  at  term  ;  the  gall-bladder  at  that  period  resembles 
a  white  thread,  its  inferior  extremity  being  the  largest,  and  its  cavity 
exceedingly  contracted.  At  five  months  the  volume  of  the  liver  is  much 
greater,  the  texture  more  condensed,  and  the  gall-bladder  more  apparent; 
the  secretion  of  bile  then  begins,  and    continues  to  augment   thereafter 


DIAGNOSIS    OF    PREGNANCY.  28'/ 

throughout  pregnancy.  We  have  just  stated  what  appear  to  us  to  bt  the 
principal  elements  of  the  bile.  At  the  seventh  month,  the  gall-bladder  is 
tilled  with  a  yellow  secretion,  and  a  considerable  quantity  of  this  is  also 
found  in  the  intestinal  canal. 

2.  Meconium. — During  the  early  periods  of  the  intra-uterine  life,  the 
digestive  canal  is  merely  moistened  by  a  little  fluid,  but  a  more  abundant 
secretion  begins  to  take  place  towards  the  third  month.  According  to  Lee, 
the  stomach  then  contains  a  clear,  acid,  and  non-albuminous  fluid ;  whilst 
at  the  upper  part  of  the  small  intestine  a  substance  similar  to  chyme  is 
found,  consisting  of  pure  albumen,  and  there  is  an  analogous  albuminous 
liquid  in  the  biliary  duct.  The  meconium  exists  in  the  small  intestine  only, 
prior  to  the  fifth  month,  and  is  of  a  greenish-brown  color,  but  after  that 
period  it  reaches  the  large  intestine,  becomes  of  a  darker  hue,  and  finally 
accumulates  in  the  rectum.  This  fluid  is  a  mixture  of  bile  with  the  pro- 
ducts secreted  by  the  intestinal  mucous  membrane. 

3.  Urine. — The  urine  never  fills  the  bladder  entirely  in  the  human 
embryo ;  now,  as  the  kidneys  are  developed  early,  and  their  secretion  com- 
mences at  once,  the  urine  must  certainly  be  evacuated  by  some  outlet.  On 
this  account,  certain  embryologists  have  supposed  that  the  bladder  com- 
municated originally  with  the  allantois  by  means  of  the  urachus,  and  that 
the  cavity  of  this  membrane  was  the  ultimate  reservoir  of  the  urine. 
However,  this  is  not  the  generally  received  opinion,  for,  as  we  have  else- 
where proved,  the  allantois  ceases  to  exist  in  the  human  species  as  a  distinct 
vesicle  long  before  the  development  of  the  kidneys ;  and  the  urine  must 
therefore  be  expelled  through  the  urethra  into  the  amniotic  cavity. 

That  its  evacuation  is  necessary  is  proved  by  the  facts  already  cited,  in 
which  the  existence  of  an  imperforate  urethra  led  to  extreme  distention  and 
even  rupture  of  the  bladder. 


CHAPTER    VI. 

DIAGNOSIS  OF   PREGNANCY. 

The  signs  of  pregnancy  are  divided  into  the  rational  and  the  sensible. 

The  first  comprise  all  those  characters  pointed  out  by  authors  as  existing 
in  the  earliest  periods,  by  which  they  assert  a  conception  may  be  justly 
suspected;  then  in  the  subsequent  stages,  —  the  suppression  of  the  menses, 
the  enlargement  of  the  abdomen,  the  pouting  of  the  navel,  the  phenomena 
just  studied  in  the  breasts,  the  symptoms,  or  rather  the  functional  disturb- 
ances in  the  digestive  organs,  the  condition  of  the  pulse,  the  modifications 
in  the  urine,  and  lastly,  certain  changes  that  occur  in  the  woman's  habits, 
as  well  as  in  her  moral  and  intellectual  faculties. 

§  1.  Rational  Signs. 

According  to  Aristotle,  there  is  some  ground  for  believing  the  woman  has 
conceived,  if  no  fluid  oozes  out  from  the  vagina  after  coition,  and  if  the 


ZOO  PREGNANCY. 

penis  is  unusually  dry  when  withdrawn ;  and  the  opinion  seems  to  be  uni 
versally  received  by  shepherds,  that  the  retention  of  the  semen  is  an  evi- 
dence of  impregnation.  Agreeably  to  Hippocrates,  the  eyes  become  more 
sunken,  more  languishing,  and  are  surrounded  by  a  bluish  circle,  and  spots 
of  different  sizes  appear  on  the  face.  Again,  since  the  days  of  Democritus, 
a  swelling  of  the  neck  is  also  enumerated  as  a  sign  of  conception.  How- 
ever, all  these  symptoms  have  but  little,  if  any  value,  and  I  accord  far 
greater  importance  to  the  more  voluptuous  sensation,  the  more  general 
erethism  experienced  by  some  females  during  a  prolific  coition,  by  which  a 
few  of  them  can  recognize  with  a  degree  of  certainty  that  they  have  become 
pregnant. 

1.  Suppression  of  the  Menses. — Females  cease  to  be  regular  during  preg- 
nancy; and  this  is  a  law  of  such  general  truth,  that  whenever  it  occurs  in 
a  healthy  woman,  without  a  known  cause,  and  not  attended  with,  or  followed 
by  any  moi'bid  symptom,  it  is  justly  regarded  as  a  probable  sign  of  gesta- 
tion ;  but  as  this  suppression  might  be  produced  by  a  number  of  other 
causes,  whenever  a  physician  is  consulted  about  it,  he  ought  carefully  to 
inquire  into  all  the  circumstances,  past  or  present,  which  may  have  pro- 
duced such  an  effect.  It  would  be  out  of  place  now  to  enter  into  this  diag- 
nosis but  we  may  reiterate  an  observation,  already  made  by  several  authors, 
and  which  our  experience  has  frequently  verified,  namely,  that  in  some 
young  married  women,  who  had  hitherto  been  quite  regular,  the  menses  be- 
come at  once  suppressed,  and  continue  so  for  several  months,  without  any 
known  cause;  and  this  suppression,  resulting  probably  from  the  irritation 
or  derangement  produced  in  the  genital  organs  by  the  first  conjugal 
approaches,  is  frequently  accompanied  by  an  augmented  volume  of  the  ab- 
domen, and  a  more  exalted  sensibility  of  the  mammary  glands  ;  and,  as  the 
mind  so  readily  believes  what  it  most  ardently  desires,  nothing  more  than 
this  is  wanted  to  found  a  hope  of  a  commencing  pregnancy.  Hence  the 
physician  must  exercise  great  discretion  in  his  diagnosis,  when  consulted  on 
so  delicate  a  subject. 

The  menses  may  continue  during  pregnancy  ;  thus  they  frequently  appear 
in  the  earlier  months,  more  rarely  during  the  first  five  or  six  months,  and 
what  is  still  more  unusual  by  far,  they  may  exist  during  the  whole  period  of 
gestation. 

Numberless  observations  of  this  kind,  recorded  by  authors,  prove  the 
truth  of  these  assertions,  and  we  also  can  bear  testimony  to  the  same  point ; 
thus,  we  saw  some  females  in  1837-38,  who  were  evidently  pregnant,  and  in 
whom  the  menses  flowed  at  the  usual  periods,  and  lasted  for  the  same  num- 
ber of  days;  one  of  them  assured  us  that  she  menstruated  during  the  first 
'ive  months,  and  that  her  courses  appeared  on  the  second  of  each  month, 
and  lasted  for  two  days,  just  as  she  had  them  previously.  Again,  two 
females  came  under  my  observation  at  the  Hotel  Dieu,  whose  cases  have 
been  already  published  in  my  thesis,  who  were  regular  throughout  the 
whole  term  of  pregnancy.  DunaKof  Montpellier),  Haller,  and  Mauriceau 
likewise  cite  similar  cases;  but  notwithstanding  all  this,  some  accoucheur? 
still  deny  that  women  can  be  regular  whilst  pregnant. 

M.  Moreau,  who  professes  this  belief,  has,  however,  often  known  females 


DIAGNOSIS     OF     PREGNANCY.  23tJ 

to  have  sanguineous  discharges  at  variable  periods  during  gelation,  but 
the  irregularity  of  their  appearance,  the  qualities  of  the  blood  itself,  and 
the  greatness  or  smallness  of  its  amount,  serve  to  distinguish  these,  in  his 
estimation,  from  a  true  menstrual  discharge.  The  remark  of  M.  Moreau  is 
certainty  applicable  to  many  cases,  but  the  instances  above  cited,  and  num- 
bers of  others  that  might  be  quoted  from  various  writers,  do  not  permit  iiir 
to  entertain  a  doubt  that  a  woman  may  menstruate  during  pregnancy. 

On  the  other  hand,  females  may  become  pregnant  without  ever  having 
had  their  menses;1  and  the  same  is  true  of  some  others  in  whom  they  are 
suppressed  either  by  accident,  from  the  progress  of  age,  or  in  consequence 
of  nursing.2 

All  those  anomalies  will  be  understood  without  difficulty,  if  we  do  but 
recollect  that,  although  the  appearance  of  the  menses  is  always  connected 
with  the  ovarian  evolution,  the  latter  may  take  place  without  being  accom- 
panied by  the  menstrual  flow.     (See  Menstruation.*) 

Deventer,  Baudelocque,  and  Chambon  furnish  accounts  of  women  who 
were  regular  only  during  gestation  ;  the  case  cited  by  Deventer  is  particu- 
larly curious,  from  the  opportunity  he  had  of  observing  this  fact  in  four 
successive  pregnancies  of  the  same  woman.  Finally,  Desormeaux  believes 
from  his  observations,  that  in  certain  years,  and  often  without  any  apparent 
cause,  a  greater  number  of  women  have  their  menses  during  gestation,  even 
where  they  were  completely  suppressed  during  former  pregnancies.  Does 
this  result,  as  he  appears  to  think,  from  atmospheric  influence,  or  is  it  pure 
chance?     For  my  part,  I  am  unable  to  decide  the  question. 

Though  it  is  important  to  be  aware  of  these  exceptional  cases,  it  is  equally 
necessary  to  guard  against  the  general  tendency  to  a  belief  of  the  marvel- 
lous.   It  should  not  be  forgotten,  that  the  continuance  of  the  menses  during 

1  A  young  woman  presented  all  the  signs  of  pregnancy,  and  although  she  had  never 
menstruated  previous  to  that  period,  her  courses  then  appeared  and  continued  during 
the  whole  of  gestation.     (Perfect,  Cases  of  Midwifery,  vol.  ii.  p.  71.) 

A  lady,  aged  twenty-four  years,  during  eight  of  which  she  had  been  married,  waa 
never  regular  except  during  pregnancy,  and  each  appearance  of  her  menses  proved 
to  be  a  certain  sign  of  that  condition. 

A  woman,  who  married  at  twenty-one,  had  never  been  regular;  two  years  after- 
wards she  experienced  some  gastric  distress,  and  the  flow  appeared.  Nine  months 
subsequently,  she  was  delivered  of  a  healthy  child,  notwithstanding  the  menses  did 
not  fail  to  appear  every  month.     (Churchill,  Observ.  on  the  Diseases  of  Pregnancy,  p.  36.) 

2  Dr.  Flecliner,  of  Vienna,  relates  that  a  young  woman  of  twenty-two,  had  always 
been  regular,  but  the  menses  never  reappeared  after  the  first  accouchement,  being 
replaced  each  month  by  an  intense  headache,  accompanied  with  a  feeling  of  oppres- 
sion and  heat  in  the  forehead  and  parietal  regions.  During  the  succeeding  thirteen 
years,  she  gave  birth  to  six  healthy  children.     (Gaz.  Med.,  p.  91,  1811.) 

Dewees  states,  that  a  woman  who  had  been  married  for  several  months,  Buffered 
some  gastric  distress.  She  had  never  been  regular  but  three  times,  and  for  a  number 
of  years  there  was  a  complete  suppression.  He  directed  rhubarb  pills,  which  purged 
her  slightly,  but  did  not  relieve,  her;  six  months  afterwards,  the  abdomen  being  some- 
what enlarged,  he  was  enabled  to  ascertain  that  she  was  six  months  advanced  in  preg- 
nancy;  and  soon  after  the  menses  returned,  and  continued  regularly  until  term.  Dur- 
ing lactation,  which  lasted  a  year,  the  courses  did  not  appear;  she  then  weaned  the 
child,  and  in  a  short  period  again  became  regular,  and  this,  like  the  former,  was  the 
announcement  of  a  new  pregnancy. 


240  PREGNANCY. 

pregnancy  is  of  rare  occurrence,  and  that,  although  then  suppression  is  of 
gieat  value  as  a  point  of  diagnosis,  it  may  nevertheless  be  the  result  of  a 
variety  of  causes. 

2.  Enlargement  of  the  Abdomen.  —  An  increase  in  the  size  of  the  abdo- 
men may  be  produced  by  so  many  different  causes  that  its  slight  value  as 
a  sign  -will  be  readily  foreseen.  There  is,  however,  something  peculiar  in 
its  shape  and  mode  of  development  in  gestation.  Thus  the  abdomen  swells 
somewhat  in  the  first  month,  but  this  is  owing  to  a  collection  of  gas  in  the 
intestinal  cavity,  which,  after  remaining  a  few  weeks,  diminishes  and  dis- 
appears, whence  the  woman  often  seems  smaller  at  the  end  of  the  second 
month  than  during  the  first ;  but  whenever  this  slight  tympanitis  is  not 
manifested,  the  abdomen  is  flatter  the  first  month  than  before,  probably  be- 
cause the  uterus  settles  down  in  the  excavation.  At  the  beginning  of  the 
third  mouth,  or  at  three  months  and  a  half,  the  hypogastric  region  evidently 
becomes  more  salient,  and  the  enlargement  is  thenceforth  regular  and 
always  increasing  until  term.  Consequently,  the  tumefaction  begins  to 
show  itself  just  above  the  symphysis  pubis,  being  more  considerable  at  first 
on  the  median  line  than  elsewhere,  while  the  sides  appear  flattened  ;  after 
the  fourth  month,  the  upper  extremity  of  the  uterine  tumor  may  be  clearly 
perceived  through  the  abdominal  wall,  especially  in  thin  subjects,  by  placing 
the  woman  on  her  back  and  the  abdominal  muscles  in  a  state  of  relaxation  ; 
but  if  the  parietes  be  thick  and  tense,  palpation,  practised  in  the  manner 
hereafter  described,  will  become  necessary  to  ascertain  this  point. 

The  modifications  in  the  size  of  the  abdomen,  at  different  periods  of  ges- 
tation, have  already  been  described ;  but  its  development  is  not  always 
regular,  being,  for  instance,  much  more  rapid  in  twin  pregnancies,  and  in 
dropsies  of  the  amnios  than  in  other  cases.  Besides,  the  relation  between 
the  volume  of  the  abdomen  and  the  stage  of  pregnancy,  is  not  always  main- 
tained; thus,  some  women  are  no  larger  at  seven  or  eight  months  than 
others  are  at  five,  owing  either  to  their  high  stature,  their  breadth  of  pelvis, 
or  the  small  degree  of  projection  in  the  vertebral  column  and  upper  part 
of  the  sacrum.  On  the  contrary,  in  small  women,  more  especially  in  those 
having  a  contracted  pelvis,  and  in  whom  the  womb  is  therefore  necessarily 
raised,  during  the  early  months,  above  the  superior  strait,  the  abdominal 
protuberance  is  premature,  if  I  may  so  express  it,  and  is  much  better 
marked  at  quite  an  early  period  than  ordinary. 

The  umbilical  depression  at  first  appears  deeper,  its  bottom  seeming  to  be 
drawn  downward  and  backward  in  consequence  of  a  tension  of  the  urach us, 
occasioned  by  the  fundus  of  the  bladder  following  the  descent  of  the  uterus 
in  the  excavation.  The  circumference  of  the  ring  becomes  at  the  same  time 
the  seat  of  a  distressing  dragging  sensation,  and  is  more  sensitive  to  pres- 
sure; and  this  sensibility  is  sometimes  extended  over  a  considerable  portion 
of  the  abdominal  wall.  But  about  the  end  of  the  third  month,  that  is,  as 
soon  as  the  uterus  gets  above  the  superior  strait,  the  umbilicus  resumes  its 
normal  condition  ;  at  the  fourth  month,  it  is  less  hollow  than  before  concep- 
tion—  then  its  bottom  becomes  more  and  more  superficial  during  the  fifth 
and  the  sixth,  and  the  whole  depression  is  effaced,  and  is  found  on  the  same 
level  as  the  skin  by  the  seventh  month,  and  in  some  cases,  the  umbilical 


DIAGNOSIS     OF     PREGNANCY.  241 

ring  is  sufficiently  dilated  to  receive  the  end  of  a  finger;  finally,  in  tl  e  last 
two  months,  the  navel  forms  a  protuberance.  Not  unfrequently,  small  por- 
tions of  the  epiploon  become  engaged  in  the  ring  during  the  exertions  of 
the  female  and  project  externally. 

These  changes  in  the  umbilicus  afford  a  rational  sign  of  great  valve-., 
because  they  are  almost  constant.  I  say  almost,  for  in  a  case  observed  by 
M.  Blot,  there  existed  a  depression  three-eighths  of  an  inch  in  depth,  the 
woman  being  at  term  and  of  ordinary  embonpoint.  Though  these  altera- 
tions of  the  umbilical  depression  may  be  produced  by  a  pathological  tumor 
of  considerable  size,  or  by  an  accumulation  of  fluid  in  the  peritoneum,  it  is 
equally  true,  that  they  almost  always  exist  in  advanced  pregnancy,  and 
that  their  absence  is,  in  a  majority  of  cases,  conclusive  against  the  existence 
of  a  foetus  of  seven  or  eight  months. 

3.  The  presence  of  the  streaks,  and  especially  of  the  brown  line,  which 
extends,  as  we  have  stated,  between  the  pubis  and  umbilicus,  is  very  impor- 
tant to  the  diagnosis,  especially  in  a  primiparous  female.  The  streaks,  how- 
ever, may  be  present  whenever  the  abdomen  has  suffered  great  distention 
from  any  cause  whatever. 

4.  The  phenomena  presented  by  the  mamma?  afford,  in  the  opinion  of  Mr. 
Montgomery,  a  certain  sign  of  pregnancy.  Smellie  and  Hunter  also  con- 
sidered the  changes  in  the  areola  as  a  positive  evidence  of  this  condition. 
The  latter  surgeon,  indeed,  did  not  hesitate  on  one  occasion,  when  examin- 
ing a  dead  body,  to  declare  from  this  sole  indication,  the  uterus  to  be 
enlarged  by  the  product  of  conception ;  as  the  examination  proceeded  the 
hymen  was  found  intact,  but  even  this  did  not  change  his  opinion,  and 
when  the  womb  was  opened  its  correctness  was  fully  confirmed.  This  fact, 
with  many  others  which  might  be  cited,  prove  the  value  of  these  signs  when 
they  exist,  which  unfortunately  is  not  always  the  case ;  any  one  of  them, 
indeed,  may  be  wanting,  and  sometimes  they  are  totally  absent.  Thus,  in 
1837,  I  saw  a  strong  and  vigorous  young  brunette  at  La  Clinique,  who  had 
advanced  to  the  end  of  gestation,  without  any  of  the  indicated  marks  appear- 
ing around  the  nipple;  and  I  have  since  made  the  same  observation  on 
several  different  occasions.  Their  absence  is  not  therefore  an  absolute  proof 
of  the  non-existence  of  pregnancy,  so  that  their  importance  in  this  respect 
has  been  exaggerated  by  some  English  surgeons.  These  cases,  however,  are 
rare,  and  I  should  diagnosticate  as  almost  certain  the  existence  of  preg- 
nancy in  a  young  woman  who  had  never  borne  children,  and  whose  breasts 
presented  both  a  brownish-colored  areola,  the  tubercles,  and  the  freckled 
characters  before  described.  But  in  those  who  have  had  children,  it  is  very 
difficult  to  determine  whether  these  signs  result  from  the  modifications  of 
the  breast  in  former  pregnancies,  or  from  a  new  conception.  In  such  cases 
we  have  only  the  testimony  of  the  women  themselves  to  rely  on,  and  this 
more  especially,  if  but  a  short  time  has  elapsed  between  the  hist  and  the 
present  gestation. 

[We    have    examined    a   young    woman    in    whom    both  vagina    and    uterus  were 

absent,  although  the  external  genital  parts  were   well   formed.     Pregnancy  in    such 

a  case   is  evidently  impossible,   yet   here  the  true  areola  was  of  a  very  dark  color. 

and  the   dotted   one   very  decided.     Still,  the  deepened   color  of  the    breasts,   when 

16 


2-A2  PREGNANCY. 

well  marked,  is  a  good  rational  sign,  though  its  absence  is  far  from  disproving  the 
existence  of  pregnancy.  In  brunettes,  the  true  areola  almost  always  darkens  as 
the  dotted  one  forms.  Such,  however,  is  not  the  ease  with  blondes,  in  whom  the 
color  of  the  breasts  is  far  less  decided,  and  in  women  of  a  ruddy  complexion  it  is 
generally  absent  even  at  the  end  of  gestation.] 

5.  I  have  never  been  able  to  appreciate  the  reputed  value  of  the  signs 
founded  on  the  state  of  the  pulse  of  pregnant  women,  for  although  it  has 
always  seemed  more  developed,  fuller,  and  harder,  I  could  discover  nothing 
further  concerning  it. 

6.  The  disorders  of  digestion,  as  well  as  of  the  moral  and  intellectual 
faculties,  are  of  but  secondary  diagnostic  importance ;  they  can  do  little  more 
than  direct  the  attention  of  the  possibility  of  a  doubtful  pregnancy,  but  as 
they  belong  more  properly  to  the  pathology  of  gestation,  they  will  be 
Btudied  hereafter. 

7.  Alterations  of  the  Urine.  —  Having  treated  at  length  of  the  production 
of  Kyesteine  in  the  urine  of  pregnant  women,  we  merely  state  here  that  its 
presence  is  not  as  certainly  diagnostic  as  some  authors  have  supposed.  Yet 
its  existence  in  the  urine  of  an  otherwise  healthy  woman  is  an  important 
rational  sign. 

Finally,  it  will  be  perceived  that  no  one  of  the  rational  signs  whose  diag- 
nostic value  has  just  been  discussed  is  conclusive,  when  taken  singly; 
excepting,  however,  the  changes  undergone  by  the  breasts,  which,  if  well 
marked  in  a  primiparous  female,  may  of  themselves  remove  all  doubts  as 
to  pregnancy. 

But  although,  singly,  these  various  signs  may  only  give  rise  to  doubts, 
their  union  furnishes  a  sum  of  probabilities  nearly  equivalent  to  certainty, 
a  certainty  which,  however,  could  never  be  complete  until  after  a  determina- 
tion of  the  sensible  signs,  which  we  shall  next  proceed  to  examine. 

§  2.  Sensible  Signs. 

All  the  sensible  signs  of  pregnancy  are  derived  either  from  auscultation 
or  the  touch.  Hence,  we  must  carefully  study  these  two  means  of  explora- 
tion, as  well  as  the  results  which  they  furnish. 

A.  Of  the  Touch. — The  touch,  considered  in  an  obstetrical  sense,  is  the  art 
of  ascertaining  the  condition  of  the  various  hard  and  soft  parts  in  the  female, 
which  contribute  to  the  great  act  of  reproduction  ;  and  it  consists  in  the 
exploration  of  those  parts  by  aid  of  the  finger  and  hand  applied  to  the 
vulva,  vagina,  and  rectum,  or  upon  the  abdomen. 

The  touch  is  practised  under  various  circumstances,  for  the  purpose  of 
ascertaining  the  existence  and  stage  of  the  gestation  ;  the  imminence  of  an 
approaching  accouchement;  the  progress  of  the  travail;  the  presentation 
and  position  of  the  foetus;  the  nature  and  energy,  or  the  feebleness  of  the 
contractions ;  and  the  character,  volume,  and  situation  of  obstacles  pre- 
sented by  the  hard  or  soft  parts,  which  might  prevent  the  spontaneous 
termination  of  labor,  and  demand  the  resources  of  art.  The  fact  that  any 
moment  in  the  life  of  the  accoucheur  may  call  for  its  exercise,  is  of  itself  an 
evidence  of  its  great  importance,  and  of  the  necessity  for  practising  it. 
With  some  experience,  any  one,  whatever  be  the  shape  or  size  of  his  finger, 


DIAGNOSIS    OF    PREGNANCY.  2W 


n,ay  acquire  such  a  degree  of  skill  in  the  .ouch  as  will  bear  bin,  through 

"^."rtWeCtTisheartened  by  the  difficulties  met  at  the 
Let  no  student  ,  f  ghort  a  nuger,  for  thu 

ZZZ;X^n9ZaU  and  those  pedants  are  unworthy  of 
credence  who  seize  a  hand,  and  after  examining  it  gravely,  reject  t  1 
dUdam exclaiming,  »  Vou  wiU  never  be  an  accoucheur  with  such  a  hand 
a  tat'  'Woln!  generally,  have  shorter  fingers  than  ourselves,  yet  they 
"come  very  perfecHn  the  touch  ;  and  I  repeat,  that,  unless  there  is  a  mad- 
formation  of  the  hand  or  fingers,  anybody  may  learn  by  practice  to  touch, 

"I  *Cw  Si  -The  index-finger  is  usually  employed  for  this  purpose; 
after  bin"  ex  ended,  it  is  entered  horizontally  in  the  fissure  between  the 
„  ,es  until  arrested  by  the  soft  parts,  and  the  index  is  then  drawn    .awards, 
as  fr  as    he  opening  of  the  vulva.     I  prefer  this  method  to  the  one  m 
!4cl   the  fin™  is  carried  from  before  backwards,  in  such  a  manner  as  to 
uass  o  -er  the"  clitoris  and  the  meatus  urinarius,  because  fnction  against 
nm  e  oarts  should  always  be  avoided  with  the  greatest  care.    In  brmging 
eL'^f  on    behind  forwards,  it  would  not  be  possible,  except  through 
„=s  ntlfoen ce,  to  confound  the  anal  orifice  with  the  vaginal  opening,  and 
ffiZS.  found,  the  index  is  first  pressed  almost  directly  backwards 
uoti   o  e4hirdof  it  has  penetrated  into  the  vagina,  and  then  by  strongly 
denies    n'  the  wrist,  the  operator  gives  his  finger  a  nearly  vertical  direction 
o   hat  the  thumb  may  be  applied  against  the  anterior  face  ot  the  symphysis, 
Lalial  bonier  of  the  index  be  directed  in  front,  and  its  cubital  border  be 
nhced  against  the  anterior  perineal  commissure,  which  it  serves  to  push 
CI     The  other  three  fingers  vary  in  position,  «^£*£* 
„„,1  mnre  esneciallv  to  the  object  in  view ;  for  example,  if  deniable  to 
"I"   the  m  ■         uatcd  on  the  posterior  plane  of  the  excavation  with  .he 
explo.e  t  ,e  p  m  (he  penneum>  pressing 

i:  tt.  r  up  b    .'.,    rlal'bordc'r  cf  the  medics ;  but  if,  on  the  other  hand, 

ewh  to  perform  the  ballottement,  or  to  explore  the  parts  on  the  anterior 

1,        twill  be  more  convenient  to  flex  the  thumb  and  the  other  three 

fi  i     ;   into  the  palm,  the  index  alone  being  extended,  with  is  palmar 

X  Erected  il,  front.     Stein  directs  the  medius  to  be  joined  with  the 

in-er,  but  this  is  generally  useless,  and  often  inconvenient,  for  although 

the  tw?  fingers  may  possibly  penetrate  a  little  deeper,  the  sensafon  is  not 

so  clear  as  that  obtained  by  one. 

P hvsicians  should  accustom  themselves  to  touching  with  both  hands  for 
.her  are  some  diseases  of  women,  and  some  posit.ons  of  the  cetus,  w  Inch 
■  ,  ,  "be  accoucheur  to  use  the  left  hand.  Or,  it  may  also  happen  that 
a  wound  upon  the  right  will  necessarily  require  the  left  to  be  substituted, 
'ihoimh  for  all  ordinary  purposes  the  right  is  sufficient. 

Tim  woman  should  be  placed  either  in  the  erect,  or  the  recumbent  posi- 
Honouring  the  examination,  according  to  circumstance*.    In  the  commence- 
ment  ""pregnancy,  it  is  better,  as  a  general  rule,  to  have  her  lying  down 
Tcaise  "in   this  position,  the   head    being    propped   up,  and   the   in.erio 
extr  mi  ies  flexed  and  separated,  the  abdominal  muscles  are  thrmvn  mto  a 


211  PREGNANCY. 

Btate  of  relaxation,  and  thus  the  development  of  the  uterus  cai.  more  easily 
be  determined.  Again,  such  diseases  as  prevent  the  female  from  standing 
erect,  may  also  require  the  same  posture.  But  at  a  more  advanced  period, 
either  position  may  be  used  indifferently,  though  most  frequently  the  bal- 
lottement  can  be  accomplished  better  while  the  woman  is  standing.  In 
this  latter  case,  her  loins  should  lean  against  a  wall  or  some  piece  of  furni- 
ture ;  a  chair  must  he  placed  at  each  side  for  her  hands  to  rest  upon,  and 
the  upper  part  of  her  body  is  to  be  slightly  flexed  forward. 

Where  any  difficulties  are  encountered  in  the  exploration,  it  is  advisable 
to  touch  in  both  positions. 

Before  operating,  the  accoucheur  should  anoint  his  finger  with  some 
unctuous  substance,  fat,  butter,  oil,  mucilage,  &c,  for  the  double  object  of 
rendering  the  introduction  easier  and  less  painful  to  the  woman,  and  to 
protect  himself  from  the  contagion  of  any  disease  she  may  be  affected  with. 

When  the  patient  is  recumbent,  the  accoucheur  places  himself  at  her  side, 
the  right  one,  if  he  intends  using  the  right  hand,  and  on  the  left,  if  the 
other  is  to  be  employed.  One  hand  is  then  placed  upon  the  abdomen,  while 
the  other  is  engaged  in  the  vaginal  exploration ;  and  this  precaution  is 
especially  advisable,  when  the  ballottement  is  practised,  in  order  to  fix  the 
fundus  uteri,  and  keep  it  steady.  In  passing  the  finger  over  the  perineum, 
and  before  entering  the  vagina,  we  ascertain  the  presence  or  absence  of  the 
fourchette,  or  the  inequalities  that  supply  its  place  after  a  labor;  and  as 
the  index  enters  the  vagina,  it  should  examine  the  condition  of  the  external 
labia,  the  length  and  width  of  the  vagina,  its  mucous  membrane,  whether 
smooth  or  rugous,  the  various  diseases,  tumors,  or  degenerations  that  may 
exist  on  the  surface  or  in  the  substance  of  its  walls,  and  the  condition  of  the 
rectum,  whether  full  or  otherwise.  Hereafter,  we  shall  have  occasion  to 
speak  of  this  process  as  a  mea'ns  of  diagnosis  in  the  various  vices  of  con- 
formation. 

All  these  explorations  being  made,  the  next  step  is  to  examine  the  neok 
of  the  uterus,  and  learn  its  modifications  in  form,  consistence,  situation, 
direction,  and  in  the  dimensions  of  its  cavity;  all  which  have  been  carefully 
described.  (See  page  130,  et  seq.)  The  finger  may  detect  the  development 
of  the  body  of  the  uterus,  by  ascertaining  the  spreading  out  of  its  inferior 
part.  During  the  first  six  or  eight  weeks  of  pregnancy,  the  changes  in  the 
uterus  are  practically  limited  to  the  body  of  the  organ,  which  loses  its  nulli- 
parous  pear  shape  and  bellies  out  over  the  cervix  in  all  the  transverse 
diameters,  particularly  antero-posteriorly,  BO  that  it  resembles  very  much  an 
old  fashioned  fat-bellied  jug;  at  the  same  time  the  muscular  substance  be- 
comes less  firm,  giving  to  the  palpating  finger  a  peculiar  feeling  of  resiliency 
and  compressibility.  These  changes,  first  noted  by  Hegar,  are  considered  by 
him  to  be  an  unfailing  sign  of  pregnancy,  and  his  researches  have  been  cor- 
roborated by  Grandin  (A7".  Y.  Med.  Bee,  1886),  Compes  and  others.  The 
recognition  of  this  sign  requires  a  certain  degree  of  expertness  in  bimanual 
palpation  and  familiarity  with  the  sensation  communicated  to  the  finger  by 
the  multiparous  uterus,  and  by  the  uterus  pathologically  altered.  Owing  to 
the  normal  slight  ante-curvature  of  the  uterus,  it  is  best  noted,  in  most  cases, 
in  the  anterior  cul-de-sac,  where  the  finger,  instead  of  following  the  line  of 
the  cervix  in  a  gentle  curve  up  on  to  the  body,  is  at  once  conscious  of  a 


DIAGNOSIS    OF     PREGNANCY.  245 

swelling  out  of  the  body  over  the  cervix,  and  on  bimanual  pressure  the 
body  is  felt  to  be  resilient  and  compressible.  Until  toward  the  third  month, 
the  organ  is  almost  wholly  within  the  excavation,  and  its  mobility  is  very 
slight,  in  consequence  of  its  restrained  position,  whilst  in  the  ordinary 
unimpregnated  state,  it  may  be  carried  to  the  right  or  left,  forward  or  back- 
ward, by  simply  pressing  with  the  finger  on  the  side  of  the  neck. 

2.  The  Aiml  -Examination.  —  The  accoucheur  is  very  seldom  obliged  to 
lulroduce  his  finger  into  the  rectum,  but  still  a  partial  obliteration  of  the 
vagina  may  render  such  an  exploration  necessary;  it  might  also  be  useful 
where  there  were  reasons  for  supposing  a  young  girl  to  be  pregnant,  who 
insisted  upon  her  virginity.  For  the  necessity  of  sparing  the  hymen,  which 
may  possibly  be  intact,  renders  the  vaginal  touch  very  difficult.  In  cases 
where  a  tumor  exists  at  the  posterior  part  of  the  vagina,  it  is  sometimes 
difficult  to  decide  whether  the  enlargement  is  located  in  the  recto-vaginal 
septum,  or  is  attached  to  the  bony  structure.  Here  the  diagnosis  is  verv 
important,  for  the  course  to  be  pursued  in  the  two  cases  would  be  widely 
different,  and  all  doubt  may  be  removed  at  once  by  introducing  the  index 
into  the  rectum,  and  the  thumb  into  the  vagina. 

B.  The  Passive  Movements,  or  Ballottement.  —  This,  according  to  most 
authors,  is  a  sensation  analogous  to  that  produced  by  placing  a  ball  of 
marble  in  a  bladder  full  of  water,  and  then  striking  the  bladder  with  the 
finger  just  under  the  spot  where  the  ball  rests,  when  the  latter  is  thrown  up, 
and  falls  back  from  its  own  weight  upon  the  finger  which  displaced  it.  This 
comparison,  however,  only  holds  good  at  a  certain  period  of  gestation,  and 
we  shall  again  take  occasion  to  refer  more  particularly  to  this  point.  To 
perform  the  ballottement,  M.  Velpeau  directs  the  index  finger  of  one  hand 
to  be  placed  under  the  cervix,  and  the  palmar  face  of  the  other  hand  over 
the  fundus  uteri ;  then,  by  a  sudden  movement  of  the  finger  in  the  vagina, 
the  uterus  is  to  be  pushed  upwards;  being  movable,  free,  and  the  only  solid 
body  in  the  amniotic  liquid,  the  foetus  ascends,  strikes  the  point  diametrically 
opposite,  and  falls  back  upon  the  finger  which  gave  it  the  impulse. 

But  as  this  mode  will  not,  I  believe,  afford  any  satisfactory  results  in  the 
majority  of  cases,  I  recommend  students  to  pursue  the  following  plan  in 
performing  the  operation :  the  vaginal  finger  should  not  be  placed  under 
the  cervix,  because  it  will  then  be  separated  from  the  fcetus  by  the  whole 
length  of  the  neck,  and  of  course  the  finger  cannot  recognize  so  clearly  the 
descent  of  the  displaced  body ;  but  rather  in  front  of,  or  behind  the  neck 
(according  to  the  woman's  position  ),  upon  the  walls  of  the  body  itself,  for  then 
the  index  is  only  removed  from  the  substance  to  be  examined  by  the  very 
thin  walls  at  the  inferior  region  of  the  uterus,  and  it  detects  very  readily 
the  least  motion  of  the  inclosed  foetus. 

If  the  woman  is  standing,  the  index  should  be  introduced  in  a  vertical 
position,  with  its  palmar  face  turned  forward,  and  the  other  three  fingers 
flexed  into  the  palm,  and  as  the  symphysis  pubis  scarcely  exceeds  an  inch 
and  a  half  in  length,  the  digital  extremity  of  the  forefinger  easily  passes  its 
superior  part,  and  reaches  the  body  of  the  organ,  where  it  almosl  always 
encounters  a  hard  globular  tumor  formed  by  the  head  of  the  foetus;  then  a 
light,  (|  lick  Mow  is  to  be  given   by  it,  after  which   the  finger   must  remaili 


246-  PREGNANCY. 

immovable  on  the  part  struck.  This  shock  should  be  made  in  a  direction 
from  below  upwards  and  from  behind  forwards,  by  suddenly  flexing  the 
first  phalanx.  This  last  recommendation  I  deem  very  important ;  for  in 
the  great  majority  of  cases,  the  uterus  is  inclined  forwards,  its  long  diameter, 
like  that  of  the  foetus,  corresponding  very  nearly  to  the  axis  of  the  superior 
strait.  Now  if,  under  these  circumstances,  the  shock  be  communicated  to 
the  presenting  part  of  the  child  from  below  upwards,  and  from  before  back- 
wards, as  generally  done,  it  is  evident  that  the  motion  given  to  it  will,  at 
furthest,  be  but  a  slight  movement,  of  displacement  or  jolting,  but  never  one 
of  ascension,  which  in  fact  would  be  impossible,  because  by  the  direction 
of  the  blow  the  foetus  is  pushed  against  the  posterior  uterine  wall,  and  not 
along  the  axis  of  its  cavity. 

The  ballottement  may  also  be  effected  when  the  woman  is  recumbent,  by 
acting  in  the  manner  I  have  just  indicated,  but  it  is  then  generally  necessary 
to  place  the  finger  upon  a  point  somewhat  nearer  to  the  neck,  sometimes 
before,  but  at  others  behind  it.  The  erect  position,  however,  is  usually  the 
more  favorable  for  the  perception  of  the  ballottement,  and  therefore  pre- 
ferable. 

It  sometimes  happens,  about  the  fifth  month  of  gestation,  that  if  the 
woman  be  standing,  the  vaginal  touch  does  not  afford  the  sensation  of 
ballottement ;  but  if  she  be  directed  to  lie  down,  and  the  vaginal  finger  be 
applied  upon  the  uterine  wall,  whilst  the  body  of  the  womb  is  forcibly 
depressed  by  the  other  hand  placed  near  the  umbilicus,  the  vaginal  finger 
is  struck  by  some  part  or  other  of  the  foetus,  which  is  displaced  by  the  ex- 
ternal pressure. 

At  an  early  period  of  pregnancy,  it  is  sometimes  possible  to  perceive  the 
ballottement  by  simply  feeling  the  abdomen.  If  the  woman  be  placed  on 
her  side,  in  a  horizontal  position,  the  foetus,  in  obedience  to  gravity,  descends 
to  the  lowest  points.  If  the  hand  be  then  glided  beneath  the  side  of  the 
abdomen  which  touches  the  bed,  some  part  of  the  foetus  will  be  distinguished 
and  may  be  readily  displaced,  but  soon  returns  to  its  original  situation. 

This  sign  usually  becomes  valuable  about  the  fourth  month,  for  before 
that  period  the  foetus  is  generally  too  small,  and,  possibly,  the  uterine  walls 
are  too  thick.  Again,  it  varies  much  after  that  time:  for  instance,  our 
search  is  not  always  successful  in  the  fifth  month,  the  small  size  of  the  child 
permitting  it  to  change  position  very  easily;  on  one  day  it  is  found  without 
difficulty,  and  on  the  following  it  defies  all  efforts  at  detection. 

Towards  the  seventh  month,  the  ballottement  is  in  general  the  most 
clearly  recognized,  since  it  is  at  this  period,  especially,  that  the  finger  per- 
ceives the  solid  mass,  inclosed  and  swimming  in  a  liquid,  to  rise  up  and 
shortly  afterwards  to  fall  back  upon  it;  but  the  sensation  is  no  longer 
perceptible  at  the  end  of  the  eighth  or  the  beginning  of  the  ninth  month, 
unless  there  happens  to  be  an  unusual  amount  of  water,  for  then  the  foetus 
has  become  too  large.  The  finger  can  indeed  raise  it,  but  the  friction 
againsl  tlif  walls  of  the  uterus  almost  destroys  the  tendency  to  ascend. 
The  mobility  of  the  tumor  is  readily  detected,  but  it  now  leaves  the  finger 
which  impels  it;  it  is  a  displacement  in  mass  rather  than  ballottement. 
Finally,  in  the  latter   periods  of  gestation,  flic  head  pushing  the  uterine 


DIAGNOSIS     OF     PREGNANCY.  247 

wall  before  it,  engages  in  the  superior  strait,  sometimes  even  gets  low  down 
in  the  excavation,  thus  becoming  jammed  in,  as  it  were,  and  of  course  the 
hallottemcnt  is  then  altogether  impossible. 

Writers  declare  this  sign  to  be  a  certain  indication  of  pregnancy  ;  but  the 
proposition  is,  perhaps,  somewhat  too  absolute  :  for  example,  it  is  possible 
for  a  stone  resting  in  the  bas-fond  of  the  bladder  to  lead  to  an  enor,  and  1 
once  met  with  a  case  which  might  readily  cause  a  mistake  of  this  kind. 
During  the  time  I  acted  at  the  obstetrical  clinic,  as  chef  de  clinique,  a 
woman  was  subjected  to  the  touch,  who  declared  herself  pregnant,  and 
advanced  three  or  four  months;  at  first,  I  examined  her  in  the  recumbent 
position,  and  found  all  the  negative  signs  of  gestation,  but  one  of  my 
advanced  pupils  then  performed  the  same  manipulation  in  the  standing 
posture,  and  declared  that  he  perceived  the  ballottement,  when  I  re-exam- 
ined her,  and  found  the  following  condition  of  things  :  The  neck  was  strongly 
pushed  backwards  and  a  little  to  the  left ;  it  was  slightly  softened,  and 
sufficiently  patulous  to  admit  the  extremity  of  the  finger.  (This  woman 
afterwards  acknowledged  she  was  delivered  only  four  months  previously.) 
As  the  finger  left  the  cervix,  and  advanced  just  behind  the  symphysis  pubis, 
it  encountered  a  large  resisting  surface,  which  was  evidently  the  body  of 
the  organ,  and  then,  by  giving  a  slight  blow,  a  movable  body  was  felt  there. 
which  immediately  fell  back  upon  the  finger,  exactly  as  the  foetus  wduld  in 
the  fourth  month.  I  confess  that  at  first  I  believed  her  pregnant,  and  re- 
touching her  in  the  recumbent  state,  I  once  more  remarked  the  negative 
signs,  but  my  finger  could  not  now  detect  the  substance  that  had  been  sc 
easily  moved  when  she  was  standing.  At  the  third  examination,  I  dis- 
covered an  anteversion  of  the  womb,  so  complete  that  its  anterior  face  had 
become  inferior  or  horizontal,  and  it  was  over  nearly  the  whole  extent  of 
this  face  the  finger  had  passed  in  examining :  and  further,  I  found  that  the 
fundus  uteri,  situated  behind  the  symphysis  pubis,  was  the  light  movablo 
body  which  had  produced  the  sensation  of  ballottement. 

If  a  similar  case  should  occur  again,  it  might  give  rise  to  uncertainty  in 
diagnosis,  and  on  that  account  I  concluded  to  make  it  public  through  this 
work. 

There  are  also  some  particular  positions  of  the  foetus  in  which  the  ballotte- 
ment would  be  of  little  service:  for  instance,  in  those  of  the  breech  it  is 
generally  very  difficult,  and  nearly  impossible  in  those  of  the  trunk.  In 
two  cases,  however,  I  succeeded  in  detecting  a  small  part,  which,  from  its 
diminished  size,  must  have  been  an  elbow,  wrist,  or  heel;  and  this,  together 
with  the  other  signs,  satisfied  me  that  it  was  a  position  of  the  trunk.  U. 
1  latin,  who  attended  one  of  these  women  in  her  accouchement,  found  a 
presentation  of  the  left  shoulder ;  the  other  was  delivered  at  the  Clinique, 
and  like  the  first,  verified  my  diagnosis. 

2.  Palpation  of  the  Abdomen.  —  An  exploration  of  the  abdomen,  says 
Schmitt,  is  of  great  importance  in  diagnosis,  and  should  always  be  resorted 
to  when  it  is  desirable  to  ascertain  whether  pregnancy  exists.  It  is  often, 
indeed,  more  instructive,  and  furnishes  surer  results,  than  the  internal 
examination. 
Some  obstacles  are,  however,  met  with  in  this  mode  of  research.     Thus 


248  PREGNANCY. 

1,  the  walls  of  the  abdomen  may  be  too  thick ;  2,  its  muscles  may  be  very 
tense;  3,  the  bladder  may  be  greatly  distended  with  urine,  and  the  intes- 
tines with  gas  or  fecal  matter;  4,  lastly,  a  fixed  pain  in  the  hypogastric 
region,  rendering  any  pressure  there  often  insupportable  to  the  patient. 

The  too  great  thickness  of  the  walls  of  the  abdomen  is  the  only  one  of 
these  difficulties  which  is  permanent,  but  which,  nevertheless,  frequently 
renders  the  palpation  of  the  abdomen  entirely  fruitless  ;  for  as  the  tension 
and  sensibility  of  the  walls  are  but  temporary,  the  exploration  may  be 
deferred  to  a  more  favorable  opportunity,  and  the  bladder  and  rectum  may 
always  be  evacuated  beforehand. 

These  obstacles  are  of  rare  occurrence,  the  examination  being  generally 
quite  easy,  owing  to  the  flexibility  of  the  walls  of  the  abdomen. 

In  order  to  practise  it,  the  female  must  lie  down  in  such  a  way  that  her 
hips  shall  be  elevated,  the  head  flexed  on  the  chest,  and  the  thighs  on  the 
abdomen  ;  in  a  word,  so  as  to  relax  the  abdominal  muscles  completely. 
Whilst  in  this  position,  the  abdomen  should  be  first  examined  with  both 
hands,  so  as  to  ascertain  its  form,  size,  tension,  resistance,  and  hardness, 
especially  in  the  sub-umbilical  region.  In  the  earlier  months  of  gestation, 
if  the  parietes  are  not  too  thick,  a  round  tumor,  of  fleshy  consistence,  can 
be  detected  rising  out  of  the  pelvis,  sometimes  in  the  middle,  and  at  others 
a  little  towards  the  right  or  the  left  side ;  during  the  first  two  months  it 
seems  to  rise  higher  above  the  pubis  than  in  the  course  of  the  third,  which 
fact  is  readily  accounted  for  by  the  sinking  down  of  the  organ,  occasioned 
by  its  increasing  weight  and  volume.  This  tumor,  which  is  the  womb, 
rises  gradually  toward  the  epigastrium  as  gestation  progresses,  and  it  often 
becomes  necessary,  in  order  to  form  some  idea  of  the  time  at  which  labor 
win  probably  occur,  to  ascertain  the  exact  amount  of  its  elevation.  The 
following  is,  I  think,  the  best  mode  of  accomplishing  this  object:  Place 
the  ends  of  the  eight  fingers  immediately  above  the  symphysis,  and  then 
continue  to  ascend  gradually  so  long  as  they  feel  any  resistance,  for  when 
the  fundus  uteri  is  gained,  the  resistance  suddenly  ceases,  and  the  fingers 
sink  deeper  as  they  glide  over  the  convexity,  which  is  thus  recognized  with- 
out difficulty. 

The  uterine  tumor,  which  is  at  first  quite  resisting,  becomes  less  so  as 
-^station  advances;  sometimes,  however,  it  is  so  soft  as  to  be  barely  dis- 
tinguishable. An  attentive  examination  will  enable  us  to  detect  the 
following  characters:  1.  It  always  remains  circumscribed  and  retains  its 
oval  form  ;  2.  It  presents  a  certain  amount  of  elasticity,  similar  to  that  of 
a  cyst  filled  with  serum ;  3.  If  this  manual  exploration  be  continued  in  the 
Miine  direction,  the  examiner  will  detect  greater  or  lesser  parts  of  a  single 
irregular  mass,  which  are  movable  and  easily  displaced  like  bodies  sus- 
pended in  water.  Often,  indeed,  these  movable  parts  may  be  recognized 
as  belonging  to  the  foetus. 

As  a  part  of  the  abdominal  exploration  should  also  be  reckoned  the 
sign  furnished  by  percussion,  namely,  a  dull  sound  over  every  part  of  the 
abdomen  occupied  by  the  developed  uterus,  instead  of  the  resonance  per- 
ceived at  other  points. 

Some  care  is  necessary  in  percussing,  during  the  first  four  or  five  months 


DIAGNOSIS    OF    PREGNANCY.  24.9 

not.  to  be  misled  by  the  dulness  which  a  distended  bladder,  or  a  patho- 
logical tumor  of  considerable  size  might  produce.  It  should  also  be  borne 
in  mind,  that  although  the  uterus  may  have  risen  to  near  the  umbilicus,  a 
clear  sound  will  be  yielded  on  percussion  throughout  the  greater  part  of 
the  sub-umbilical  region,  provided  a  few  folds  of  intestine  be  interposed 
between  the  walls  of  the  abdomen  and  the  womb. 

Sometimes  the  uterus  is  above  the  superior  strait  in  the  earliest  months. 
I  had  an  opportunity  of  observing  a  case  of  the  kind  at  the  Clinic,  with 
Professor  Dubois,  in  a  woman  who  was  advanced  six  weeks  or  two  months ; 
the  uterus  was  so  elevated,  being  found  in  the  right  iliac  fossa,"  that  at  first 
we  doubted  the  existence  of  pregnancy,  which  however  was  real,  as  was 
proved  more  positively  several  weeks  after,  and  fully  justified  by  the  event 
of  the  case. 

The  palpation  of  the  abdomen  and  the  vaginal  touch  are  in  most  cases 
practised  simultaneously ;  we  shall,  therefore,  point  out  the  signs  which 
this  joint  investigation  furnishes  at  the  different  periods  of  pregnancy. 

In  the  first  three  or  four  months  the  uterus  either  remains  wholly  within 
the  lesser  pelvis,  or  else  its  fundus  projects  somewhat  above  the  superior 
strait.  In  the  first  case,  it  will  he  easily  discovered  by  the  vaginal  touch 
that  the  entire  excavation  is  occupied  by  a  slightly  movable  tumor,  with  a 
smooth  and  regular  external  surface.  In  the  second  case,  the  lower  half 
of  the  lesser  pelvis  is  empty,  but  the  examination  of  the  abdomen,  con- 
ducted according  to  the  rules  above  mentioned,  discovers  the  tumor  formed 
by  the  womb  in  the  hypogastrium.  The  first  point  to  be  ascertained  is 
the  exact  size  of  the  uterus,  and  this  can  only  be  determined  by  the  double 
exploration  spoken  of:  the  finger  having  been  introduced  into  the  vagina, 
is  applied  directly  on  the  neck,  or,  still  better,  against  the  anterior  or  pos- 
terior portion  of  the  inferior  segment  of  the  uterus,  while  the  other  hand 
placed  above  the  pubis,  presses  down  the  muscular  walls,  and  searches  for 
the  tumor  formed  by  the  fundus  uteri ;  the  womb  is  thus  included  between 
the  finger  in  the  vagina  and  the  hand  on  the  hypogastrium,  and,  of  course, 
the  volume  of  the  organ  may  be  thus  ascertained,  and  a  comparison  made 
between  it  and  the  unimpregnated  uterus.  Moreover,  its  displacement  in 
mass  can  be  very  easily  recognized  in  this  position.  To  accomplish  this, 
the  finger  should  remain  applied  as  above  stated,  and  when  the  hand 
slightly  depresses  the  fundus,  the  finger  in  the  vagina  recognizes  the  de- 
pression ;  and  the  counter-proof  may  be  made  by  endeavoring  to  raise  the 
uterus  from  below,  by  pressing  strongly  on  the  inferior  part,  which  is  found 
deep  in  the  excavation. 

But  the  tumor  which  is  felt  in  the  lesser  pelvis,  or  in  the  hypogastric 
region,  may  be  either  formed  by  the  uterus,  or  developed  in  the  adjacent 
parts.  In  the  latter  case,  the  womb  will  generally  found  to  be  displaced, 
and  pressed  by  the  tumor  against  one  of  the  sides  of  the  pelvis ;  and  if 
the  neck  be  traced  from  below  upwards,  the  finger  will  detect  a  line  of 
demarcation  between  the  wall  of  the  uterus  and  the  pathological  tumor; 
sometimes,  it  can  even  be  insinuated  between  them.  The  motions  to  winch 
the  neck  is  subjected  are  not  usually  communicated  to  the  tumor,  and  vice 
versti.  Finally,  the  neck  will  exhibit  none  of  the  changes  peculiar  to 
pregnancy. 


250  PREGNANCY. 

Hitherto  y>  e  have  only  demonstrated  that  the  uterus  is  developed,  bui 
the  question  arises,  what  is  the  cause  of  that  development?  The  solution 
is  nearly  always  difficult ;  we  may  state,  however,  that  when  the  womb  ig 
enlarged  by  a  product  of  conception,  its  walls  are  generally  more  flexible 
than  if  the  enlargement  were  dependent  upon  some  chronic  disease;  and 
that,  after  a  little  practice,  this  suppleness  can  be  detected  by  carrying  the 
finger  to  the  posterior  surface  of  the  body,  which  may  be  done  in  conse- 
quence of  the  depression  and  retroversion  of  the  fundus.  The  uterine  wall 
then  offers  about  the  same  resistance  as  an  oedematous  limb,  or  perhaps 
still  nearer,  that  of  caoutchouc  when  slightly  softened  in  hot  water. 

The  tumor  detected  either  by  the  vaginal  touch,  or  by  depressing  the  ven- 
tral parietes,  is  rounded  and  smooth  throughout,  and  does  not  present  any 
of  those  irregularities  observed  in  cancerous  or  fibrous  degenerations  of  its 
walls ;  and  this  fact,  together  with  the  preceding  observation,  will  serve  to 
distinguish  a  morbid  state  from  a  true  gestation. 

It  certainly  will  not  prove  quite  so  easy  to  determine  whether  the  enlarge- 
ment is  caused  by  a  foetus,  or  the  presence  of  a  mole  in  the  cavity ;  in  fact, 
I  do  not  believe  this  diagnosis  is  possible,  except  at  a  very  advanced  stage, 
and  then  the  absence  of  the  foetal  inequalities,  the  non-appearance  of  its 
movements,  auscultation,  &c.,  might  suffice  to  remove  the  doubts  on  the 
subject. 

In  some  women,  the  womb  becomes  congested  and  considerably  tumefied 
at  the  menstrual  periods.  Now  this  state  may  readily  be  confounded  with 
a  commencing  pregnancy,  the  more  particularly,  because  at  those  epochs 
the  neck  usually  becomes  softer  and  dilates  a  little;  and  I  know  no  way  of 
escaping  this  error,  if  the  woman  insists  that  she  is  pregnant,  and  experiences 
the  various  rational  signs  of  that  condition.  In  two  cases  of  the  kind  I 
have  met  with,  I  only  succeeded  in  detecting  the  falsity  of  my  diagnosis  by 
examining  the  woman  a  second  time,  two  or  three  weeks  after;  for  these 
females,  who  were  used  as  subjects  for  practising  the  touch  at  the  Clinique, 
wished  to  be  considered  pregnant ;  but,  unhappily  for  them,  the  fortune 
which  aided  in  the  first  examination,  deserted  them  at  the  second  ;  for,  being 
ignorant  of  the  cause  of  my  mistake,  they  returned  at  a  time  still  more  dis- 
tant from  their  menstrual  period. 

On  the  whole,  then,  there  is  no  certain  sign  of  pregnancy  during  the  first 
three  or  four  months;  yet  it  becomes  almost  certain,  when  the  sensible  signs 
above  indicated  coincide  with  the  presence  of  the  rational  ones,  in  a  healthy 
woman  who  can  have  no  intention  of  deceiving  us  as  to  her  condition  ;  still, 
in  a  medico-legal  case,  the  physician  should  express  his  doubts,  and  demand 
a  new  examination  at  a  more  advanced  period.  But  if  it  is  not  always  pos- 
sible at  the  beginning  of  a  gestation  to  prove  that  it  does  exist,  we  can,  at 
least  in  the  great  majority  of  cases,  satisfy  ourselves  positively  that  it  does 
not ;  for  most  frequently  the  unimpregnated  state  of  the  organ  can  be 
readily  made  out. 

3.  Active  Movement*  of  the  Foetus.  —  The  existence  of  pregnancy  is  an- 
nounced during  the  last  five  months  by  certain  signs  that  are  far  more 
reliable  than  any  of  those  hitherto  mentioned ;  these  arc  the  fcetal  move- 
ments, which  have  improperly  been  called  the  active  and  passive,  but  bettei 


DIAGNOSIS     OF     PREGNANCY.  251 

designated  by  M.  Stoltz  as  the  movements  proper  and  the  communicated 
ones.  We  have  already  studied  the  communicated  ones  in  treating  of  bal- 
lottement  and  palpation  of  the  abdomen;  so  that  it  only  remains  to  describe 
the  active  movements. 

The  woman  generally  perceives  the  foetal  movements  at  about  four  months 
and  a  half,  although  the  muscles  of  the  infant  had  contracted  long  ere  this, 
unconsciously  to  her ;  for  every  accoucheur  must  have  detected  the3f 
motions  by  placing  his  hand  upon  the  abdomen,  at  a  time  when  the  mother 
herself  still  doubted  her  own  pregnancy.  Now  these  movements  are  exces- 
sively feeble  at  first,  and  produce  a  kind  of  tickling,  or  rather  a  sensation 
analogous  to  that  of  the  crawling  of  a  spider;  they  gradually  become  more 
characteristic,  and  may  then  be  classified  in  two  species.  One  of  these  is 
produced  by  the  movements  of  the  whole  trunk,  or  some  of  its  parts,  the 
first  of  which  are  recognized  by  a  quivering  that  is  perceptible  to  the  female, 
while  the  partial  motions  give  rise  to  quite  large  projections,  which  are  even 
visible  through  the  abdominal  walls ;  the  other,  on  the  contrary,  are  blows, 
certain  small,  short  strokes,  which  at  times  are  violent  enough  to  elicit  cries 
from  the  sufferer,  and  these  shocks  are  evidently  produced  by  the  action  of 
the  thoracic  or  inferior  extremities  of  the  child.  Such  movements,  so  dis- 
tinct and  clear  to  the  mother,  would  seem  to  be  an  infallible  sign  of  gesta- 
tion, and  yet  such  is  by  no  means  the  case,  since  it  is  not  at  all  uncommon 
to  find  women,  whose  veracity  is  beyond  question,  asserting  that  they  have 
felt  them  for  a  long  period,  and  sometimes  the  motions  have  even  been  per- 
ceived by  the  husband  or  other  persons,  yet  without  their  being  pregnant. 

The  history  of  one  of  the  English  queens  is  well  known,  who,  believing 
she  had  felt  the  motions  of  a  child,  dispatched  couriers  with  the  happy  news 
to  all  the  foreign  courts,  but  proved  to  be  only  the  commencement  of  a 
dropsy !  Such  errors  are  frequent,  and  there  are  but  few  accoucheurs  who 
have  not  met  with  many  of  them  in  practice.  Consequently,  the  physician 
should  not  rely  in  this  matter  upon  the  statement  of  the  woman,  but  should 
perceive  them  for  himself  before  hazarding  an  opinion.  It  would  seem, 
indeed,  that  in  some  cases,  the  intestinal  movements,  the  rapid  passage  of 
gas  in  the  intestines,  certain  partial  and  irregular  contractions  of  the  ab- 
dominal muscles,  and  the  pulsation  of  a  large  artery,  especially  when  situated 
behind  any  tumor  which  it  raises  at  every  beat,  have  often  deceived  not 
only  the  patient,  but  even  her  medical  attendant. 

Some  females,  from  the  desire  of  simulating  pregnancy,  have  acquired 
the  power  of  contracting  their  abdominal  muscles  in  so  singular  a  manner, 
that  many  able  accoucheurs  have  been  deceived,  and  believing  that  they 
felt  the  foetal  movements,  have  consequently  pronounced  them  pregnant. 
(Montgomery,  p.  84.) 

These  motions  may  be  detected  by  the  vaginal  touch  in  certain  positions 
of  the  breech,  or  even  of  the  trunk,  but  we  must  rely  chiefly  on  the  abdo- 
minal palpation  for  their  detection.  In  general,  it  is  only  necessary  to  place 
the  hand  flat  on  the  abdomen,  or  to  make  use  of  slight  pressure,  to  perceive 
them  ;  though  if  they  are  feeble  and  infrequent,  it  is  hetter  to  dip  the  hand 
in  some  very  cold  liquid,  and  then  place  it  suddenly  upon  the  skin.  This 
rapid  change  in  the  temperature  of  the  abdomen  probably  reacts  upon  the 


252  PREGNANCY. 

infant,  for  it  generally  moves  convulsively.  I  believe,  with  Dr.  Tyler 
Smith,  that  the  sudden  impression  of  cold  is  more  likely  to  produce  a  rapid 
contraction  of  the  abdominal  muscles  or  uterus,  than  to  act  directly  upon 
the  foetus,  and  that  its  use  might  readily  deceive  as  to  the  nature  of  the 
motions  which  it  occasions. 

I  prefer  placing  a  hand  upon  one  of  the  sides  of  the  abdomen,  and  strik- 
ing with  the  other  on  a  point  opposite ;  for  the  foetus  then  rarely  fails  to 
move  briskly  as  though  to  resist  the  impulse. 

As  before  stated,  the  movements  begin  to  be  felt  about  the  end  of  the 
fourth  month.  To  this  law,  however,  there  are  numerous  exceptions;  thus, 
fome  women  perceive  them  as  early  as  the  latter  half  of  the  third  month, 
others  not  before  the  fifth,  sixth,  seventh,  or  eighth  months  of  gestation. 
One  woman,  who  had  advanced  to  the  latter  period,  was  brought  to  the 
Clinique,  in  consequence  of  a  fall  in  the  street,  and  she  assured  us  that  she 
had  never  felt  the  movement  prior  to  the  accident.  We  have  already 
alluded  to  the  person,  seen  by  us  at  La  Charite,  under  the  care  of  Professor 
Fouquier,  who  was  delivered  at  term  of  a  very  healthy  child,  but  the 
motions  of  which  were  neither  perceptible  to  the  mother  nor  ourselves. 

Mauriceau,  Delamotte,  and  many  others,  bring  forward  similar  cases. 
Bat  the  most  remarkable  of  all  is  the  one  reported  by  Campbell.  I  knew 
a  lady,  he  says,  the  mother  of  nine  children,  who,  excepting  in  her  first 
pregnancy,  never  perceived  any  motious  of  the  foetus;  but  she  was  herself 
very  inanimate  and  passive,  and  what  was  still  more  singular,  the  children 
were  equally  nonchalant  with  herself.  Whenever  ascites  complicates  the 
pregnancy,  these  motions  are  very  indistinct,  thus  affording  an  evidence 
that  it  is  the  abdominal  walls,  and  not  the  uterus,  which  perceive  the 
impulse. 

After  the  movements  have  been  distinctly  felt,  they  sometimes  diminish 
without  any  appreciable  cause,  both  in  frequency  and  intensity,  and  then 
altogether  disappear,  which  circumstances  demand  the  most  serious  atten- 
tion of  the  accoucheur,  as  it  is  in  general  an  unfortunate  symptom. 

I  believe  this  spontaneous  cessation  of  the  active  movements  may  usually 
be  referred  to  a  congested  state  of  the  uterus,  which  reacts  on  the  child's 
health.  But  whatever  may  be  the  value  of  this  opinion,  it  is  quite  certain 
that  bleeding,  under  such  circumstances,  has  always  produced  a  favorable 
result;  for  when  not  delayed  too  long,  the  movements  reappear  soon  after, 
and  hence  I  cannot  recommend  the  measure  too  highly. 

4.  Of  Auscultation  as  applied  to  Pregnancy. — M.  Mayor,  of  Geneva,  first 
detected  the  pulsations  of  the  foetal  heart  by  auscultation ;  but  this  dis- 
covery, originally  published  by  him  in  1818,  had  been  entirely  forgotten, 
when  M.  de  Kergaradec  announced,  in  1823,  that  if  the  abdomen  of  a 
woman  who  has  passed  the  first  half  of  her  pregnancy  be  carefully  auscul- 
tated, two  sounds,  which  are  perfectly  distinct  in  character,  will  be  recog- 
nized: one  of  them,  consisting  of  double  pulsations,  or  rather  of  redoubled 
ones,  according  to  the  expression  of  M.  Stoltz,  is  evidently  produced  by  the 
movements  of  the  foetal  heart,  and  has  been  compared,  with  some  reason, 
to  the  ti  king  of  a  watch  enveloped  in  a  napkin  ;  the  other  is  a  kind  of 
rustling,  unattended  l>v  shocks,  and  consequently    without  beating,  being 


DIAGNOSIS    OF    PREGNANCY.  253 

characterize*]  by  simple  pulsations,  accompanied  by  the  souffle,  which  have 
been  successively  compared  to  the  sibilant  murmur,  or  to  the  sound  of  an 
erectile  tumor,  or  varicose  aneurism  ;  this  is  called  the  bellows  sound  (bruit 
dc  souffle).  Another  bellows  murmur,  of  more  frequent  occurrence  than 
the  former,  is  termed  the  murmur  of  the  cord,  and  will  be  studied  after  the 
preceding.1 

[At  the  end  of  the  third  month  the  pulsations  of  the  foetal  heart  may,  therefore, 
be  heard,  though  not  as  a  general  rule.  Careful  and  long  continued  auscultation 
at  this  period,  however,  often  enables  us  to  detect  with  the  stethoscope  sudden  and 
repeated  blows,  which  would  seem  to  be  produced  by  rapid  motions  of  the  foetus. 
The  sensation  is  sometimes  so  clear,  and  leaves  so  little  doubt  as  to  its  cause,  that 
the  sound  occasioned  by  the  displacement  of  the  foetus  in  the  amniotic  fluid  may  be 
accepted  as  a  useful  sign  in  the  diagnosis  of  pregnancy,  and  one  which,  in  a  diffi- 
cult case,  ought  not  to  be  neglected.  It  cannot,  however,  be  always  detected,  inas- 
much as  it  is  necessary  that  the  foetus  should  move  briskly  at  the  moment  of 
observation.] 

1.  Sound  of  the  Heart. — The  pulsations  of  the  heart  generally  become 
perceptible  in  the  course  of  the  fourth  or  fifth  month,  though  more  fre- 
quently during  the  latter,  and  often  then  at  an  elevated  part  of  the  abdo- 
men near  the  umbilical  region  ;  in  one  case,  however,  I  thought  I  heard 
them  a  little  before  the  fourth  month,  but,  unfortunately,  I  could  not 
re-examine  the  female  until  six  weeks  afterwards.  M.  Depaul  declares 
that  he  has  heard  them  at  the  end  of  the  third  month  and  in  the  eleventh 
week. 

These  pulsations  are  far  more  frequent  than  those  of  the  mother's  heart ; 
ranging,  as  they  do,  from  one  hundred  and  thirty  to  one  hundred  and  sixty 
per  minute ;  and,  moreover,  they  are  very  often  accelerated  or  diminished, 
without  our  being  able  to  detect  the  cause  of  the  changes. 

Like  most  observers,  I  have  several  times  remarked  that,  if  the  foetus 
exhibited  any  violent  movements  during  the  examination,  the  pulsation 
increased  and  became  very  difficult  to  county  but  they  are  not  influenced 
by  any  variations  in  the  mother's  pulse,  whatever  may  be  their  cause. 

The  dorsal  region  of  the  child  seems  to  transmit  the  double  pulsations 
most  easily,  and  consequently  they  are  more  clearly  perceived  at  that  part 
of  the  abdomen  which  corresponds  to  it.  This  circumstance  likewise 
explains  why  the  pulsations  change  position  so  easily  prior  to  the  seventh 
month  ;  in  fact,  it  is  only  during  the  last  three  months,  that  extensive 
movements  on  the  part  of  the  child  become  difficult,  and  its  position  nearly 
fixed. 

They  may  be  heard  most  frequently  on  the  anterior  inferior  portion  of  the 
abdominal  wall,  just  above  the  iliac  fossa,  or  still  more  rarely  on  the  median 
line,  and  not  merely  at  a  very  limited  spot,  but  over  a  radius  of  two  or 
three  inches.  In  some  cases  they  may  even  be  heard  over  more  than  half 
of  the  abdomen ;  but  it  is  always  easy  to  perceive  that  bhey  are  stronger 

1  The  character  of  this  work  prevents  our  giving  a  detailed  account? of  the  history 
of  this  important  subject.  I  cannot,  however,  too  strongly  recommend  all  who  wish 
to  be  fully  informed  upon  the  matter,  to  consult  the  excellent  Monograph  recently 
published  by  M.  Depaul.      (Truitt  de  I' Auscultation  Qbstetricale,  1847.) 


254:  PREGNANCY. 

and  clearer  at  one  point  than  elsewhere,  and  from  this  point  as  a  centre, 
thev  become  weaker  and  weaker  as  the  distance  increases.  The  intensity 
of  pulsation  is  of  course  less  marked  as  the  child  is  younger,  although,  in 
some  instances,  they  exhibit  as  much  force  in  the  sixth  month  as  at  term, 
but  this  is  very  unusual. 

As  regards  the  number  of  pulsations,  the  statement  made  by  many 
observers  that  it  is  much  more  considerable  at  an  earlier  period  than  at 
term,  is  not  absolutely  true,  for  the  fetal  heart  always  beats  with  the  same 
quickness,  saving  some  accidental  variations,  at  whatever  period  it  may  be 
examined.  Labor  produces  no  modification  of  the  foetal  pulsations  up  to 
the  moment  of  rupturing  the  membranes;  but  this  rule  fails  after  the 
amniotic  liquid  has  escaped,  because  they  are  then  generally  louder  and 
clearer,  and  may  be  heard  over  a  more  considerable  extent  of  surface,  which 
can  readily  be  explained  by  the  fact  that  the  ear  or  instrument  is  then 
nearer  the  foetus. 

When  the  contractions  become  more  energetic,  the  pulsations  are  not  so 
regular,  and  they  are  more  feeble  and  slower  while  the  contraction  lasts. 

In  those  cases  where  the  labor  is  of  moderate  duration,  the  indistinctness 
of  the  sound  of  the  heart  may  be  referred,  I  believe,  to  the  difficulty  of 
ausculting  during  the  pain ;  but  if  the  foetus  has  been  too  long  subjected 
to  uterine  pressure — as  where  the  labor  has  been  unusually  prolonged — the 
number,  force,  and  regularity  of  the  pulsations  sensibly  decrease 

.Most  observers  have  asserted  that  the  sounds  are  not  always  perceptible, 
and  M.  Stoltz  even  declares  that  they  cannot  be  heard  whenever  the  dorsal 
region  is  directed  backwards,  unless  some  part  of  the  thorax  be  in  contact 
with  a  portion  of  the  uterine  walls  which  may  be  explored.  For  my  own 
part,  I  have  not  failed,  for  several  years  past,  to  hear  them  in  examinations 
made  after  the  sixth  month,  in  all  cases  where  the  children  were  living ; 
and  as  my  researches  have  now  extended  to  at  least  seven  or  eight  hundred 
women,  I  feel  convinced  that  we  can  always  distinguish  them  after  that 
period,  in  any  position  of  the  foetus  whatever. 

M.  Dubois  was  the  first  to  point  out  the  fact,  that  the  sound  of  the  foetal 
heart  has  sometimes  a  peculiar  resonance,  resembling  the  metallic  tinkling, 
a  singularity  which  I  have  twice  had  the  opportunity  of  observing  at  the 
Clinique.  This  remarkable  sonoriety  is  most  frequently  met  with  in  women 
in  whom  the  uterus  is  distended  by  a  great  quantity  of  fluid.  There  are 
also  some  circumstances  which  render  the  pulsation  a  little  obscure  and 
somewhat  difficult  to  hear;  thus,  for  instance,  a  lumbo-posterior  position  of 
the  foetus,  a  large  quantity  of  water,  by  which  the  uterine  walls  are  greatly 
distended,  and  a  sufficient  depression  of  them  by  the  stethoscope  to  approach 
the  child  prevented  ;  the  interposition  of  several  folds  of  intestines  between 
the  abdominal  walls  and  the  uterus,  and  the  existence  of  borborygmi,  are 
nil  so  many  circumstances  calculated  to  render  the  perception  of  the  pulsa- 
tions more  difficult,  although  not  absolutely  impossible. 

The  beatings  of  the  foetal  heart  are  composed  of  two  distinct  sounds,  the 
second  being  stronger  and  more  sonorous  than  the  first ;  but,  u.  a  great 
in  ijority  of  cases,  both  of  them  may  be  heard  quite  distinctly. 

M.  Nsegele,  however,  appears  to  think  that  enly  a  single  3ound  is  heard 


DIAGNOSIS    OF    PREGNANCY.  255 

under  certain  circumstances,  and  I  have  sometimes  made  the  same  observa- 
tion;  but  it  has  always  seemed  to  me  that  the  perception  of  only  one  sound 
might  either  be  referred  to  bad  manipulation  on  my  part,  or  else  to  some 
one  of  those  circumstances  just  described  having  prevented  the  application 
of  the  stethoscope  over  a  point  near  enough  to  the  back  of  the  foetus.  Thus, 
though  I  have  frequently  heard  but  a  single  sound  at  first,  after  changing 
the  instrument,  others  became  clearly  perceptible.  I  am  happy  to  extract 
the  following  paragraph  from  the  thesis  of  M.  Carriere,  a  pupil  of  M.  Stoltz, 
which  fully  confirms  my  opinion.  He  says:  "I  have  remarked  that  the 
single  character  of  the  fcetal  pulsations  here  described,  is  most  likely  to  be 
observed  when  the  point  examined  approaches  the  fundus  of  the  uterus." 

Like  all  useful  discoveries,  obstetrical  auscultation  has  had  its  opponents 
as  well  as  its  partisans;  and  though  the  former  are  daily  diminishing  in 
number,  the  latter  certainly  have  injured  their  cause  by  exaggerating  its 
importance  ;  we  shall,  however,  carefully  endeavor  to  ascertain  its  practical 
utility. 

a.  It  has  been  stated  that  a  perception  of  the  pulsations  of  the  foetal  heart 
was  a  certain  sign  of  pregnancy,  as  also  that  the  absence  of  this  sound, 
positively  determined  by  several  examinations  made  after  intervals  of  some 
hours,  subsequent  to  the  sixth  month,  announces  with  certainty  the  death 
of  the  foetus;  supposing,  of  course,  we  have  a  satisfactory  assurance  of  the 
previous  existence  of  gestation. 

[It  is  a  very  rare  circumstance,  says  M.  Depaul,  for  the  pulsations  of  the  fcetal 
heart  to  be  inaudible  during  the  three  last  months  of  gestation,  unless  the  child 
be  dead.  They  failed  to  be  detected  in  but  eight  cases  out  of  nine  hundred  and 
six,  examined  at  this  period.] 

There  is,  notwithstanding,  one  circumstance  which  might  lead  to  a  sus- 
picion of  pregnancy  even  when  the  uterus  was  really  empty;  it  is  this:  in 
certain  females  the  pulsation  of  the  heart  is  felt  and  heard  as  low  down  as 
the  sub-umbilical  region,  and  we  can  imagine  that  if,  in  such  persons,  under 
the  emotions  naturally  produced  by  an  unjust  suspicion  of  gestation,  or, 
from  the  influence  of  any  febrile  movement,  the  circulation  be  accelerated, 
the  pulsations,  from  their  number  and  rapidity,  might  be  mistaken  for  those 
of  a  foetus;  but  in  such  cases,  all  errors  of  diagnosis  may  be  easily  avoided 
by  observing:  1st.  The  perfect  isochronism  between  the  pulse  at  the  wrist 
and  the  abdominal  beatings;  and  2d.  That  the  intensity  of  pulsation  con- 
stantly increases  as  the  precordial  region  is  approached  ;  which  two  pecu- 
liarities are  never  presented  by  the  sound  of  the  foetal  heart. 

b.  Can  a  twin  pregnancy  always  be  recognized  by  auscultation?  It  is 
said  that,  in  most  cases,  the  existence  of  two  children  in  the  uterine  cavity 
may  be  known  by  the  following  sounds:  1st.  The  sound  of  the  heart  will  be 
heard  at  two  distant  parts  of  the  abdomen  ;  and  2d.  The  want  of  isochronism, 
and  of  frequency,  which  may  sometimes  be  detected  between  these  two  series 
of  pulsations. 

These  characters  are  advanced  by  some  writers  as  indicating  a  double 
pregnancy  with  cerlainty,  but  we  shall  point  out  several  sources  of  error  on 
this  point:  thus,  it  frequently  happens  that  the  pulsations  of  a  single  heart 
resound   in   very  distant   parts.     Now,  can   this   be  referred,  as  M    Dubois 


256  PREGNANCY. 

thinks,  to  deficient  thoracic  development,  to  the  unusual  com}  arative  siz« 
of  the  heart's  cavities,  to  the  density  of  the  lungs,  or,  lastly,  to  the  position 
of  the  foetus  itself,  the  head  and  extremities  of  which,  being  applied  against 
the  thorax,  and  there  receiving  the  impulses  from  the  heart's  contractions, 
serve  to  transmit  them  to  a  greater  distance?  I  should  be  inclined  to  adopt 
this  view;  for,  whatever  be  the  explanation,  the  fact  is  certain,  and  the 
following  appears  to  me  the  best  method  of  resolving  the  difficulty:  When- 
ever the  pulsations  are  heard  at  two  distant  points,  the  line  between  these 
should  be  carefully  followed  with  the  instrument;  for  if  they  are  produced 
by  the  presence  of  two  foetuses,  the  pulsations  will  become  feeble,  or  almost 
disappear,  towards  the  centre  of  this  line;  but  if,  on  the  contrary,  they  are 
due  to  a  single  child,  they  will  be  just  as  strong  at  its  middle  part  as  at 
either  extremity. 

Again,  the  absence  of  isoehronism  in  the  pulsation  does  not  positively 
prove  the  existence  of  two  children;  for  one  series  may  be  owing  to  the 
foetal  heart,  and  the  other  belong  to  the  same  organ  in  the  mother,  the 
resonance  being  transmitted  to  the  abdominal  cavity.  Hence,  it  is  evident 
that  the  unusual  distinctness  of  the  mother's  pulsations  coinciding  with  the 
presence  of  a  single  foetus  may  lead  to  the  belief  of  a  double  pregnancy 
which  does  not  exist,  and  a  comparative  examination  of  the  pulse  then 
becomes  necessary. 

[After  all,  it  must  be  acknowledged  that  the  pulsations  of  the  fcetal  heart  may 
vary  from  one  instant  to  another,  without  our  being  able  to  comprehend  why  such 
should  be  the  case.  It  may  lead,  also,  to  a  wrong  inference  when  the  auscultation 
is  practised  at  two  different  points  successively,  inasmuch  as  a  want  of  isoehronism 
might  in  this  case  give  rise  to  the  impression  that  there  were  two  children,  whilst, 
in  fact,  there  was  heard  the  sound  of  but  a  single  heart  beating  with  variable 
rapidity.  To  avoid  all  chance  of  error,  two  practised  observers  should  place  their 
stethoscopes  over  the  two  points  where  the  sounds  are  most  clearly  heard,  and  then 
count  them  together  during  the  same  time.  Should  there  be  a  notable  difference 
between  the  two  numbers  thus  obtained,  a  twin  pregnancy  may  be  regarded  as 
certain.] 

A  double  gestation  may  be  easily  recognized,  if  the  precautions  just 
indicated  are  observed,  because,  the  twins  being  habitually  placed  one  on 
the  right  the  other  at  the  left  part  of  the  abdomen,  distinct  beatings  will  be 
clearly  heard,  if  the  stethoscope  be  successively  applied  to  each  side.  But 
this  happy  state  of  affairs  does  not  always  exist,  for  sometimes  one  foetus  is 
situated  directly  before  the  other ;  and  then  it  is  nearly  impossible,  even 
with  the  greatest  attention,  to  hear  the  heart  of  the  posterior  child ;  and, 
consequently,  when  the  other  signs  of  a  twin  pregnancy  are  present,  the 
results  derived  from  auscultation  would  not  prove  its  non-existence.  Is  it 
necessary  to  add,  that  equal  care  should  be  taken  to  abstain  from  hasty  deci- 
sions in  those  cases  in  which  there  is  reason  to  believe  that  one  of  the 
children  is  dead ''. 

c.  Can  we  appreciate  the  state  of  the  child's  health  or  disease,  of  its 
debility  or  vigor,  during  labor,  by  means  of  auscultation? 

This  question,  which  was  brought  before  the  Academy  by  a  memoir  of 
M.  Bodson,  and  which  gave  rise  to  a  remarkable  report  by  M.  P.  Dubois, 


DIAGNOSIS   OF   PREGNANCY.  257 

is  certainly  one  of  1he  most  curious  and  interesting  suojecls  of  &iudy ;  for 
if  we  could  possibly  judge  from  the  signs  furnished  by  auscultation,  of  the 
integrity  of  the  fetal  life,  no  uncertaiutv  could  arise  with  regard  to  the 
course  to  be  pursued  when  the  labor  is  100  long  delayed,  after  the  rupture 
of  the  membranes ;  for  the  feebleness  and  relaxation,  or  the  excessive  fre- 
quency of  the  foetal  pulsations ;  the  interniission  and  irregularity  of  their 
rhythm  ;  the  absence  of  the  second  stroke  ;  or  the  complete  cessation  of  this 
phenomenon  during  the  uterine  contraction,  and  the  slowness  of  its  return 
after  the  pain  has  ceased,  would  sufficiently  authorize  a  prompt  termination  ; 
whilst  the  opposite  phenomena  would  justify  delay. 

These  signs,  and  more  especially  the  irregularity  of  the  pulsations,  which 
appears  the  most  important  of  all,  indicate  in  the  clearest  manner  that  the 
fcetus  is  in  a  state  of  suffering;  and  hence  they  should  serve  as  a  formal 
indication  to  the  accoucheur  to  remove  the  infant  promptly  from  the  danger 
which  threatens  it,  by  an  artificial  termination  of  the  labor.  But,  as  M. 
Dubois  has  very  judiciously  remarked,  there  is  not  then  a  sufficient  integrity 
of  circulation  to  establish  the  extra  uterine  life;  for,  although  the  foetal 
pulsations  may  be  still  regular  and  sonorous  at  the  moment  of  birth, 
yet  the  child  has  suffered  so  much  from  the  long  pressure  of  labor,  that  the 
respiration  cannot  be  established  ;  and  hence,  in  this  respect,  the  accoucheur 
should  not  rely  upon  auscultation  alone  for  judging  of  the  opportune  moment 
for  the  intervention  of  art,  because  other  considerations  quite  as  important 
should  influence  his  decision ;  still,  however,  this  is  a  method  of  diagnosis 
that  is  never  to  be  neglected. 

2.  Souffle  of  the  Cord.  —  M.  Nsegele,  junior,  has  recently  described  a  bel- 
lows murmur,  which  he  attributes  to  the  pulsations  of  the  umbilical  cord, 
and  compares  it  with  the  sound  produced  by  the  beating  of  the  carotids  in 
chlorosis,  and  the  murmur  consists,  he  states,  of  a  simple  pulsation  which  is 
caused,  as  he  thinks,  by  the  winding  of  the  cord  around  the  neck  of  the 
fcetus,  or  by  its  compression  between  the  child's  back  and  the  uterine  walls; 
the  sound  increases  after  the  escape  of  the  liquor  amnii,  and  its  force  is 
greater  in  proportion  as  the  arteries  of  the  cord  are  the  more  developed,  and 
subjected  to  greater  tension. 

In  the  positions  of  the  head,  it  is  situated  below  the  umbilicus,  but  higher 
up  in  those  of  the  breech,  and  it  seems  to  descend  during  the  expulsion  of 
the  foetus.  Sometimes  a  bellows  murmur  is  heard  accompanying  the  cardiac 
pulsations,  especially  at  the  first  sound,  but  it  appears  difficult  to  reconcile 
this  circumstance  with  the  interruption  in  the  circulation  caused  by  any 
pressure  on  the  cord.  Since  M.  Najgele,  junior,  pointed  out  this  peculiarity, 
several  others  have  noticed  it,  and  I  also  have  met  with  it  at  different  times, 
where  nothing  would  indicate  even  a  slight  compression  of  the  cord,  or  any 
winding  around  the  neck. 

Does  this  belong  to  the  fcetal  heart,  as  M.  Dubois  and  M.  Depaul  believe? 
Indeed,  the  latter  states  that  he  has  detected  this  sound,  which  he  had  pre- 
viously heard  during  the  intra-uterine  life,  by  ausculting  the  infant  imme- 
diately after  birth.  But  nine  other  cases,  he  says,  turned  out  differently, 
and  oblige  me  to  state  the  facts  as  they  occurred.  The  foetal  murmur 
occupied  a  part  of  the  uterus  entirely  removed  from  that  where  the  beating 
17 


25S  PREGNANCY. 

of  the  heart  was  detected ;  the  latter  being  pure,  and  unmixed  with  any 
murmur.  Five  of  these  children  were  boru  with  one  or  several  turns  of  the 
cord  about  the  neck,  whilst  in  the  sixth,  it  surrounded  the  lower  part  of 
the  thorax.  The  remaining  three  were  free  from  anything  of  the  kind.  All 
were  born  living,  and  on  none  of  them  was  it  possible  to  detect  a  souffle  in 
the  cardiac  region  immediately  after  birth. 

The  question  must  therefore  be  decided  by  new  observations  ;  for,  although 
the  sound  may  be  produced  by  the  compression  of  the  cord,  the  compression 
often  exists  without  the  abnormal  murmur. 

3.  Uterine  Souffle. — Numerous  denominations,  each  of  which  is  founded 
on  its  supposed  nature,  have  been  applied  to  this  sound ;  for  instance,  M. 
Kergaradec  thought  it  was  produced  in  the  utero-placental  circulation,  and 
hence  gave  it  the  name  of  the  placental  murmur;  on  the  other  hand,  M. 
Bouillaud,  and  many  others,  have  subsequently  assigned  its  seat  (which,  to 
say  the  least,  is  very  probable)  to  the  large  arterial  trunks  placed  on  the 
posterior  abdominal  plane,  where  they  are  subjected  to  considerable  pressure 
from  the  developed  uterus,  and  they  have  denominated  it  on  this  account 
the  abdominal  souffle ;  and  still  more  recently,  M.  Paul  Dubois  has  endeavored 
to  prove  that  it  originates  in  the  vessels  which  ramify  in  the  substance  of 
the  uterine  wall  itself,  whence  he  has  called  it  the  uterine  souffle.  But  as 
we  shall  take  occasion  hereafter  to  discuss  these  three  opinions,  which  em- 
brace all  our  present  knowledge  on  the  subject,  we  will  pass  them  over  here. 
In  general,  the  bellows  murmur  may  be  heard  as  soon  as  the  uterus,  by 
rising  above  the  superior  strait,  becomes  accessible  to  the  stethoscope — that 
is,  a  little  earlier  than  the  sound  of  the  fcetal  heart;  in  fact,  M.  Delens 
asserts  he  has  detected  it  at  the  third  month,  and  Dr.  Kennedy  towards  the 
tenth,  eleventh,  or  the  twelfth  week.  M.  Depaul  has  also  made  the  same 
observation ;  but  as  there  is  a  very  great  difficulty  in  approaching  the  uterus 
at  so  early  a  period,  these  facts  are  certainly  exceptional. 

The  murmur  undergoes  some  very  singular  modifications  during  the  course 
of  pregnancy  :  thus,  we  do  not  hear  it  in  every  instance ;  again,  it  is  not  at 
all  unusual  for  it  to  escape  detection  for  a  long  time  after  having  once  been 
heard,  and  then  to  reappear  somewhat  later;  sometimes  even  we  may 
auscult  for  several  minutes  in  vain,  when  it  suddenly  appears  directly 
under  the  ear,  augments,  becomes  quite  loud  and  distinct,  lasts  for  a  few 
moments,  then  diminishes,  and  finally  ceases  altogether. 

In  other  cases,  two  or  three  pulsations,  attended  by  blowing,  are  heard 
during  profound  silence,  but  nothing  more  after  that ;  and  on  the  other 
hand,  very  frequent  opportunities  are  afforded  us  of  observing  the  prompti- 
tude with  which  the  sound  changes  its  locality;  for  it  seems  to  pass  suddenly 
from  one  point  to  an  opposite  one,  being  sometimes  immediately  beneath 
the  ear,  at  others  very  distant:  only  covering  a  single  spot  in  the  majority 
of  cases,  but  occasionally  extending  to  two  remote  regions,  and,  what  is  very 
remarkable,  with  equal  force  and  clearness  at  both  these  points ;  further, 
the  extent  over  which  the  sound  is  heard  is  usually  quite  limited,  but  in 
Bome  instances  it  becomes  perceptible  over  a  very  large  surface,  trespassing 
upon  neaily  the  whole  anterior  abdominal  region. 
On  several  occasions  my  pupils  have  had  opportunities  of  studying  all 


DIAGNOSIS   OF   PREGNANCY.  259 

these  varieties,  which  indeed  are  almost  inexplicable,  whatever  opinion  may 
be  adopted  as  to  the  cause  of  the  sound. 

The  murmur  is  modified  during  labor  ;  for  at  the  very  instant  when  the 
pains  begin,  and  even  before  the  patient  herself  is  aware  of  them,  it  becomes 
at  once  louder,  more  sonorous,  and  more  distinct,  and  at  times  exhibits  some 
strange  modifications:  thus,  at  one  time  the  sound  heard  resembles,  par- 
tially at  least,  the  tone  of  a  reed,  or  a  tense  cord  thrown  into  vibration, 
though  as  soon  as  the  contraction  becomes  stronger  and  more  general,  it 
seems  to  grow  weaker,  appearing  at  longer  intervals,  and  finally  becoming 
imperceptible ;  but  when  the  pain  ceases,  the  sound  returns,  at  first  with  the 
intensity  it  manifested  at  the  beginning  of  the  contraction,  and  gradually 
regains  the  same  sonorousness  it  had  during  the  gestation.  Such  is  the 
order  presented  when  the  contractions  are  regular  and  energetic  ;  but  if 
they  are  false  or  irregular,  the  souffle  is  not  modified,  or  at  least  is  not  any 
stronger,  except  it  be  for  a  few  instants  only. 

It  may  likewise  be  perceived  after  the  expulsion  of  the  foetus,  and  even 
of  the  after-birth :  for  example,  M.  Carriere  says  he  heard  it  twenty-four 
hours  subsequent  to  the  delivery  of  the  placenta. 

Generally,  it  extends  towards  the  inferior  lateral  part  of  the  abdomen  ; 
more  rarely,  it  is  heard  near  the  fundus  uteri. 

The  following  is  the  result  of  295  observations,  made  by  M.  Depaul,  of 
women  who  had  passed  the  fifth  month  of  gestation ;  it  will  be  seen  that 
it  accords  with  my  own  experience.  It  was  heard  very  distinctly  182  times 
on  each  side  of  the  uterus,  at  a  short  distance  from  the  crural  arch ;  in  27 
cases,  it  appeared  on  one  side  only  ;  in  43,  towards  the  fundus  of  the  organ ; 
and  in  18,  it  was  spread  over  the  entire  surface  of  the  uterus.  Finally,  M. 
Depaul  states,  that  in  12  cases,  it  was  present  in  three  distinct  situations, 
namely,  the  fundus  of  the  womb  and  the  parts  above  the  crural  arches. 
During  the  first  half  of  the  pregnancy,  it  was  oftenest  observed  when  the 
stethoscope  was  placed  upon  the  median  line  a  little  above  the  pubis. 

The  character  of  the  sound  heard  varies  greatly ;  sometimes  it  is  short, 
abrupt,  and  separated  from  the  succeeding  one  by  a  longer  or  shorter  inter- 
val of  complete  silence,  which  is  dependent  upon  the  frequency  of  the  pulse; 
sometimes  it  is  a  prolonged  roaring,  a  true  **  bruit  de  diable,"  which  has  its 
period  of  beginning,  of  increase,  and  termination,  the  latter  blending  with 
the  next  succession. 

In  short,  it  presents  all  the  variations  of  rhythm  which  have  been  attri- 
buted to  the  chlorotic  murmurs.  Though  generally  simple  and  intermit- 
tent, it  is  sometimes  continuous  and  double  (bruit  de  diable) ;  finally,  it  may 
be  both  continuous  and  simple.  I  have  not  yet  met  with  the  typical,  double 
intermittent  sound.  Like  the  murmur  in  the  carotids,  the  rhythm  may 
change  in  a  few  moments  so  as  to  present  in  a  very  short  time  several  of  the 
varieties  just  mentioned. 

The  quality  of  the  sound  also  varies  greatly ;  and  this  not  only  in  dif- 
ferent women,  but  even  in  the  same  woman,  and  sometimes  whilst  the 
exploration  is  going  on.  Occasionally  it  is  whistling,  and  resembles  much 
the  sound  of  the  wind  blowing  through  a  badly  closed  doorway ;  again  it 
becomes  roaring,  so  as  to  imitate  the  vibrations  of  a  base  cord  ;  at  other 
times  it  is  plaintive,  suggesting  the  cpoings  of  a  turtle-dove. 


260  PREGNANCY.. 

The  seat  and  mode  of  production  of  this  sound  is  a  question  that  has 
given  rise  to  much  controversy,  though,  as  the  sound  is  synchronous  with 
the  mother's  pulse,  it  must  be  evidently  connected  with  the  maternal  vascu- 
lar system.  Thus  far  all  agree,  but  diversities  of  opinion  immediately  spring 
up  when  a  more  precise  location  of  it  is  attempted  ;  for  the  murmur  is  pro- 
duced outside  of  the  uterus,  exclaims  one  party;  not  so,  it  is  seated  in  the 
uterine  or  the  placental  vessels,  say  the  others. 

1.  The  Murmur  is  produced  in  Parts  distinct  from  the  Uterus.  —  When- 
ever a  tumor  is  developed  over  the  course  of  a  large  arterial  trunk,  the 
compression  exercised  by  it  on  the  vessel  produces  a  souffle,  and  it  is  not  at 
all  unusual,  whenever  a  pathological  tumor  is  developed  in  the  abdomen, 
to  hear  a  murmur  in  such  cases,  very  nearly  resembling  that  of  pregnancy ; 
now,  the  uterus  developed  by  a  product  of  conception  constitutes  a  consider- 
able tumor,  one  which  must  necessarily  compress  the  vessels  and  produce 
the  effect  described.  This  view  is  advocated  by  numerous  partisans,  who 
contend  that  the  murmur  does  not  begin  to  appear  until  the  uterus  really 
compresses  the  iliac  vessels  by  being  elevated  above  the  superior  strait ; 
that  it  is  usually  heard  at  the  inferior  lateral  part  of  the  abdomen,  and 
more  frequently  on  the  right  side,  because  the  uterus  is  habitually  inclined 
to  the  right;  and  lastly,  that  if,  according  to  the  plan  of  my  friend,  Dr. 
Jacquemier  (which  I  have  since  often  practised  myself),  the  female,  after 
having  been  ausculted  in  the  supine  position,  be  made  to  kneel  down,  with 
the  body  bent  forward  nearly  horizontally,  and  the  elbows  resting  on  the 
ground,  in  a  word,  in  such  a  position  as  to  throw  the  whole  weight  of  the 
uterus  upon  the  anterior  abdominal  wall,  the  murmur  will  no  longer  be 
heard,  although  distinctly  audible  before. 

In  support  of  this  opinion  the  following  considerations  may  be  adduced  : 

The  abdominal  souffle  is,  like  that  of  chlorosis,  partly  due  to  the  altera- 
tions which  the  blood  undergoes  during  pregnancy.  Whatever  theory  be 
embiaced  respecting  the  mechanism  of  these  abnormal  vascular  sounds  in 
chlorosis,  whether  they  be  attributed  to  the  diminution  of  the  corpuscles,  as 
M.  Andral  supposes,  or  to  hydremia,  according  to  M.  Beau,  and,  we  may 
add  in  passing,  this  latter  theory  seems  to  me  to  be  the  only  admissible  one, 
the  great  analogy  between  the  blood  of  chlorosis  and  that  of  pregnancy  can- 
not be  ignored. 

It  is  equally  difficult  not  to  recognize  the  entire  resemblance  between  the 
souffle  of  pregnant  women  and  that  of  chlorotic  patients.  They  exhibit  the 
same  varieties  of  rhythm,  as  also  of  tone  and  sonorousness ;  both  are  some- 
times mixed  or  composed  simply  of  buzzing,  rasping,  or  whistling  sounds, 
which  seem  to  be  alike  peculiar  to  the  early  stages  of  the  affection.  Both 
present,  if  I  may  so  express  it,  the  same  mobility  of  duration,  rhythm,  and 
intensity,  and  appear  to  be  similarly  affected  by  the  greater  or  less  pressure  of 
the  instrument,  as  also  by  changes  in  the  circulation  of  the  female  as  a  con- 
sequence of  disturbances  of  temper,  violent  movements,  &c. 

Is  it  not,  therefore,  natural  to  conclude,  that  since  pregnancy  and  chlo- 
rosis produce  the  same  changes  in  the  blood,  the  souffle,  which  is  exactly 
alike  in  both  cases,  is  also  due  to  the  same  cause  ? 

But,  it  will  be  replied,  in  chlorosis  the  murmur  is  heard  more  especially 


DIAGNOSIS     OF     PREGNANCY.  261 

in  (he  cervical  region ;  why,  therefore,  during  pregnancy  should  it,  if  due 
to  the  same  cause,  fix  itself  particularly  in  the  abdomen  ?  I  would  reply, 
in  the  first  place,  that  in  some  cases  the  cardiac  and  carotid  murmurs  have 
been  observed  in  pregnant  women ;  still  I  admit  that,  most  generally,  they 
are  not  heard  even  when  the  abdominal  souffle  is  present.  The  latter  cir- 
cumstance can  be  readily  explained,  for  it  is  in  fact  rarely  that  the  altera- 
tion of  the  blood  is  carried  to  the  same  extent  as  in  ordinary  chlorosis  ;  the 
proportion  of  globules  rarely  descends  below  one  hundred,  and  the*  amount 
of  water  is  far  from  equalling  the  enormous  proportion  which  it  reaches  in 
chlorosis.  Now,  if  it  be  true,  as  M.  Andral  supposes,  that  the  production 
of  abnormal  sounds  is  an  indication  of  a  more  advanced  alteration,  we  can 
comprehend  why  they  should  not  be  perceptible  in  the  carotids,  where  only 
poverty  of  the  blood  could  produce  them. 

The  conditions  are  not  the  same  in  the  abdominal  vessels,  for  there,  to  a 
commencing  hydrsemia,  is  superadded  a  considerable  diminution  of  the 
calibre  of  the  vessels,  which  diminution  is  a  result  of  the  compression  of  the 
uterine  tumor  ;  and  these  two  circumstances  united  are  capable  of  produc- 
ing a  souffle  which  they  would  be  unable  to  determine  singly.  The  com- 
pression of  the  arteries  thus  gives  rise  to  a  sort  of  insufficiency,  which  ren- 
ders still  more  sensible  the  slight  increase  which  the  total  amount  of  the 
blood  has  undergone. 

It  has  been  stated  that  we  have  several  times  known  the  sound  to  dis- 
appear when  the  woman  was  placed  on  all  fours,  but  that  in  other  in- 
stances it  still  remained.  M.  Depaul  recollects  having  repeated  this  ex- 
periment, with  the  effect  of  continuing  to  hear  the  uterine  murmur,  without 
the  slightest  variation.  This  last  remark,  made  by  such  observers  as  MM. 
Depaul  and  Carriere,  deserves  further  attention  on  our  part.  As  M.  Beau 
has  pointed  out,  it  is  much  more  difficult  than  would  be  supposed,  and 
sometimes  even  impossible,  to  cause  the  woman  to  assume  such  a  position 
that  the  large  arteries  shall  escape  all  compression  by  the  uterus.  The 
abdominal  walls  of  young  primiparous  women  are  too  resisting  to  yield 
under  the  momentary  weight  of  the  uterus,  and  whatever  position  be 
assumed,  they  retain  the  organ  strongly  applied  against  the  posterior  plane 
of  the  abdomen. 

M.  Beau  has  also  proved  that  this  persistence  of  the  abdominal  souffle  is 
not  peculiar  to  pregnancy,  but  that  in  the  case  of  a  woman  affected  with  a 
cyst  of  the  ovary,  shown  to  be  such  at  the  autopsy,  it  was  impossible  to 
give  the  tumor  any  position  in  which  it  ceased  to  compress  the  arteries  of 
the  pelvis,  and  consequently  to  put  an  end  to  the  murmur. 

I  would  add,  that,  whilst  admitting  that  compression  is  not  the  sole 
oause  of  the  murmur,  but  that  the  serous  plethora  of  pregnancy  also  con- 
tributes to  its  production,  it  might  be  readily  supposed  that  if  the  latter 
reach  a  certain  degree,  it  might  of  itself  give  rise  to  the  abnormal  sound, 
even  should  the  position  of  the  female  entirely  relieve  the  abdominal  ves« 
sels  from  pressure. 

The  same  remarks  will  apply  to  the  variable  results  which  are  some- 
times obtained,  when,  after  having  heard  the  sounds  on  one  side  of  the 
abdomen,  the  woman  is  made  to  reverse  her  position.     Sometimes,  we  have 


262  PREGNANCY. 

said,  it  ceases  to  be  heard ;  at  others  it  persists,  although  the  inclination 
of  the  uterus  had  removed  the  pressure  from  the  vessels  on  the  point 
opposite  the  side  upon  which  the  woman  lies.  In  the  first  case,  the  ple- 
thora was  too  slight  to  maintain  a  sound,  the  production  of  which  was 
partly  due  to  the  compression  of  the  vascular  tube;  in  the  second,  either 
the  inclination  of  the  uterus  had  not  removed  the  pressure,  or  else  the 
alteration  of  the  blood  was  alone  sufficient  to  produce  the  abnormal  sound. 
Although  MM.  Barth  and  Roger  are  disposed  to  attribute  the  abdominal 
murmur  to  pressure,  they  nevertheless  find  some  objections  which  prevent 
their  adopting  the  opinion  in  its  full  extent.  Why,  say  they,  is  not  the 
sound  increased  when  the  uterus  is  pressed  upon  with  the  stethoscope,  and 
why  does  it  sometimes  disappear  when  the  pressure  is  made  rather  stronger? 
It  is,  replies  M.  Beau,  because  the  murmurs  are  the  result  of  a  certain 
degree  of  pressure,  which  if  increased  or  diminished,  the  sounds  are  altered 
or  lessened.  The  effect  is  the  same  as  that  which  is  frequently  observed  in 
the  carotid  murmurs,  which  do  not  increase,  and  which  even  disappear, 
when  too  much  pressure  is  made  upon  the  artery  ;  and  as  these  latter 
sounds  are  sometimes  found  to  have  their  intensity  somewhat  increased  by 
a  slight  pressure,  so  the  abdominal  murmurs  are  occasionally  notably  in- 
creased when  the  uterus  is  a  little  pressed  upon. 

Finally,  how  happens  it,  say  MM.  Barth  and  Roger,  that  in  certain  cases 
in  which  no  souffle  was  heard  upon  auscultation  of  the  abdomen,  it  could, 
through  the  assistance  of  the  metroscope  of  M.  Nauche,  be  perceived  upon 
the  neck  of  the  uterus,  which  is  situated  in  the  centre  of  the  pelvic  cavity, 
and  therefore  removed  from  the  vessels  ? 

We  may  suppose,  again  replies  M.  Beau,  that  in  the  cases  in  question 
the  murmur  had  its  origin  in  the  hypogastric  arteries.  Now  the  neck  of 
the  uterus  is  nearer  these  arteries,  than  that  part  of  the  body  of  the  organ 
which  is  in  relation  with  the  abdominal  parietes.  Besides,  it  is  not  pos- 
sible that  certain  organs  which  are  poor  conductors  of  sound,  such  as  a 
mass  of  intestine  or  of  omentum,  might  have  been  interposed  between  the 
surface  of  the  uterus  and  the  walls  of  the  abdomen,  and  thus  have  pre- 
vented the  transmission  of  the  vibrations  to  the  ear? 

2.  The  Murmur  is  produced  in  the  Uterus. — Those  who  locate  the  sound 
in  the  uterine  circulation,  differ  essentially  as  to  its  precise  seat  and  the 
mode  of  its  production.  Thus,  M.  de  Kergaradec  attributes  it  to  the  pla- 
cental circulation  ;  whilst  M.  Hohl,  who  also  believes  it  is  perceived  at  the 
point  where  the  placenta  is  inserted,  locates  the  murmur  at  a  point  corre- 
sponding to  the  insertion  of  the  placenta,  and  bases  his  opinion  upon  the 
following  reasons :  1.  In  21  cases  in  which  he  removed  the  placenta  with 
his  hand,  he  found  it  adhering  where  the  souffle  was  first  heard;  2.  In  15 
cases  where  it  was  inserted  upon  the  orifice,  the  murmur  was  heard  very 
low  down  ;  3.  In  10  others  the  autopsy  revealed  the  after-birth  where  the 
souffle  had  been  distinguished  ;  4.  In  8  cases  of  version  the  same  fact  was 
discovered  directly ;  5.  In  12  cases  of  twin  pregnancy,  one  murmur  uflly 
was  heard  when  but  a  single  placenta  was  present,  and  two  distinct  ones 
when  the  after-births  were  separate;  6.  Lastly,  in  a  great  number  of  cases 
the  intensity  of  the  sound  appeared  to  be  in  direct  relation  with  the  bulk 
and  extent  of  the  placenta. 


DIAGNOSIS    OF    PREGNANCY.  263 

M.  Hohl  differs  from  M.  Kergaradec  by  supposing  that  the  sound  results 
from  the  passage  of  the  arterial  blood  into  the  venous  sinuses  of  the  placenta ; 
but,  to  refute  this  latter  opinion,  it  is  only  necessary  to  bear  in  mind  the 
great  variety  in  the  seat  of  the  murmur  during  pregnancy,  and  that  in  some 
cases  it  is  still  perceptible  after  the  delivery  of  the  after-birth. 

I  am  therefore,  like  M.  Depaul,  convinced,  that  there  is  no  relation 
between  the  point  where  the  souffle  is  heard  and  that  of  the  insertion  of  the 
placenta 

The  views  of  M.  Dubois  still  claim  a  notice ;  for  whenever,  says  this  Pro- 
fessor, the  disposition  of  the  uterine  apparatus  is  carefully  studied,  the 
freest  communication  will  be  found  to  exist  between  the  arteries  and  veins, 
the  uterine  walls  appearing  to  be  transformed  into  an  erectile  tissue,  or  one 
of  varicose  aneurisms ;  and  the  column  of  blood  brought  by  the  arteries, 
and  divided  through  their  branches,  mingles,  whilst  passing  directly  into 
the  veins,  with  the  slower  and  less  compressed  columns  contained  in  the 
canals  of  the  latter.  This  circumstance  is  incontestably  the  cause  of  the 
murmur  and  souffle  that  is  so  remarkable  in  varicose  aneurisms  and  the 
accidental  erectile  tissues,  and  it  is  very  likely  that  the  same  cause  pro- 
duces it  in  the  uterine  walls.  Hence  we  can  comprehend  why  it  is  only 
heard  at  that  period  when  the  vascular  modifications  of  the  organ  are  the 
most  marked ;  why  it  is  most  frequently  audible  over  the  spot  correspond- 
ing to  the  placental  insertion,  because  the  development  of  the  uterine 
vascular  system  is  the  most  considerable  there ;  and  finally,  why  this  sound 
may  still  be  heard  in  some  women  after  delivery,  when  the  retreat  of  the 
uterus  is  not  yet  complete,  and  the  circulation  in  its  walls  has  not  been 
reduced  to  its  condition  in  the  non-gravid  state. 

No  one,  since  the  researches  of  M.  Dubois,  has  been  able  to  rediscover  the 
large  and  free  communications  between  the  uterine  arteries  and  veins;  it  is 
in  fact  certain,  that  they  communicate  directly  in  no  other  way  than  through 
their  terminal  and  capillary  ramifications.  It  is  plain,  that  when  a  sup- 
posed anatomical  fact  is  proved  to  have  no  existence,  the  theory  which  is 
founded  upon  it  can  no  longer  be  maintained. 

There  are  still  some  other  points  concerning  the  uterine  circulation,  which 
have  recently  been  advanced:  thus,  Dr.  Corrigan  thought  the  passage  of 
the  blood  from  the  uterine  arteries  into  the  sinuses,  was  the  cause  of  the 
souffle;  and  M.  Carriere,  who  admitted  this  opinion,  added,  that  the  circula- 
tion being  much  more  active  at  the  point  corresponding  to  the  placental 
insertion,  the  sound  should  be  most  audible  on  a  level  with  that  insertion. 

M.  Depaul  has  quite  recently  repromulgated  the  views  of  Corrigan,  adding 
thereto  the  compressions  produced  both  within  and  without  by  some  port  ion 
of  the  foetal  ovoid,  and  he  attributes  an  important  influence  to  these  com- 
pressions, which,  however,  had  previously  been  brought  forward  by  M.  de 
Kergaradec,  in  explanation  of  the  frequent  variations  of  the  souffle  in  its 
seat  and  intensity. 

The  cause  of  the  sound,  says  M.  de  la  Harpe  de  Lausanne,  neither  rests 
on  a  particular  condition  of  the  blood,  nor  on  a  modification  of  its  course, 
nor  yet  in  any  peculiar  state  of  the  vessels,  but  simply  on  the  multiplicity 
of  the  vesiels  concentrating  at  the  same  point;  which  multiplicity,  b) 


264  PREGNANCY. 

increasing  the  currents  a  hundredfold,  increases  the  sounds  in  the  same 
ratio  ;  thus  rendering  those  audible  by  multiplication,  which,  taken  singly, 
were  imperceptible  to  the  human  ear.  Perhaps  a  comparison  will  serve  to 
illustrate  this  idea :  if  a  person  place  himself,  on  a  mild  day,  under  a  tree 
that  has  been  closely  pruned,  deprived  of  its  leaves,  and  only  having  some 
large  branches  left,  he  will  hear  no  sound  or  rustling  of  the  air ;  now  let 
him  pass  from  this  tree  to  another  one  better  furnished  with  branches, 
though  still  deprived  of  leaves,  and  he  will  perceive,  if  the  same  air  be 
stirring,  a  commencing  sound,  produced  by  the  branches  that  are  agitated 
in  the  wind ;  again,  the  intensity  of  sound  will  become  much  greater,  if  he 
once  more  changes  to  a  fir-tree ;  for  notwithstanding  the  leaves  of  this  latter 
are  rigid  and  immovable,  yet  they  are  innumerable ;  and  just  such  is  the 
case  with  the  placental  murmur.  In  fact,  a  liquid  cannot  circulate  in  a 
tube  without  producing  a  certain  amount  of  sound  by  the  friction  of  its 
molecules  against  the  walls  of  the  tube;  only  the  sound  is  not  detected  by 
the  ear  when  the  vascular  canal  is  isolated,  but  the  contrary  results,  when 
thousands  of  little  canals  are  found  at  the  same  point. 

[Amidst  so  many  contradictory  theories  we  shall  not  undertake  to  decide  upon 
the  mechanical  production  of  the  bellows  murmur,  but  will  endeavor  to  determine 
the  seat  of  the  sound,  premising,  however,  that  we  do  not  believe  that  it  is  pro- 
duced in  the  great  blood-vessels  which  are  situated  behind  the  uterus.  The  sound 
is  sometimes  really  so  superficial  that  it  cannot  be  produced  in  the  aorta  or  the  iliac 
vessels;  how,  besides,  will  this  explanation  enable  us  to  understand  the  facility 
with  which  it  changes  place,  a  circumstance  to  which  all  observers  can  testify? 
Finally,  we  would  add  that,  in  some  very  rare  cases,  the  sound  is  accompanied  by 
a  thrill,  which  is  easily  perceived  by  the  finger,  and  felt,  so  to  speak,  to  be  pro- 
duced behind  the  anterior  wall  of  the  abdomen.  We  regard  it,  therefore,  as  certain 
that  it  is  produced  in  the  uterus,  and  as  we  have  already  shown  that  it  cannot  have 
its  origin  in  the  placenta,  we  agree  with  MM.  Dubois  and  Depaul,  that  it  is  located 
in  the  walls  of  the  uterus.  It  is  evident,  therefore,  that  the  term  uterine  souffle 
is  the  only  one  which  can  be  properly  applied  to  it.] 

The  abdominal  souffle  is  not  of  great  practical  importance ;  its  value,  as 
a  sign,  is  limited  to  rendering  the  existence  of  pregnancy  probable.  It  may 
exist  independently  of  pregnancy,  and  does  not  always  accompany  it;  it  is 
not  influenced  by  the  life  or  death  of  the  foetus,  nor  is  it  modified  in  any 
degree  by  a  state  of  suffering  of  the  child ;  it  cannot,  in  any  case,  enable  us 
to  determine  certainly  either  the  place  of  insertion  of  the  placenta,  nor  its 
form,  size,  or  the  changes  which  it  may  undergo.  The  observations  of 
MM.  Depaul  and  Na3gele,  Jr.,  prove,  in  opposition  to  the  conclusions  of 
Hohl,  that  the  diagnosis  of  double  or  triple  pregnancies,  is  incapable  of 
assistance  from  the  souffle,  presenting  as  it  does  in  these  cases  no  modifica- 
tions which  are  not  also  observed  in  simple  pregnancies. 

Summary.  —  It  is  now  well  understood  that,  in  ausculting  the  abdomen 
of  a  pregnant  woman,  we  may  hear  both  the  pulsations  of  the  foetal  heart 
and  the  bruit  de  souflle.  The  first  is  a  certain  sign  of  pregnancy;  but  the 
gecond,  being  also  produced  by  other  causes,  only  becomes  of  importance 
when  we  have  previously  ascertained  that  the  female  has  no  other  disease. 

The  sound  of  the  heart  may  aid  in  ascertaining  the  position  of  the  foetus; 
the  souffle  can  communicate  no  information  as  to  the  place  of  insertion  of 


DIAGNOSIS    OF    PREGNANCY.  265 

the  placenta,  and  indicates  nothing  as  regards  the  child's  position ;  while 
any  feebleness,  and  more  especially  any  irregularity  or  intermittence  of  the 
heart's  pulsations,  furnish  strong  presumptive  reasons  for  believing  that  the 
foetus  is  suffering,  and  that  its  life  is  compromised. 

When  desirable  to  auscult  a  female  who  is  supposed  to  be  pregnant,  we 
must  request  her  to  lie  down  on  her  back  ;  at  the  commencement  of  gesta- 
tion this  precaution  is  indispensable ;  but  towards  the  last  it  becomes  less 
so,  and  she  may  then  be  examined  standing.  In  fact,  whatever  be  her 
position  in  the  latter  months,  this  exploration  is  quite  easy,  on  account  of 
the  dimensions  of  the  uterus  and  the  volume  of  the  foetus,  but  at  first  it  is 
nearly  always  necessary  to  flex  the  thighs  upon  the  belly,  so  as  to  com- 
pletely relax  the  abdominal  muscles,  and  of  course  this  could  only  be  done 
in  the  horizontal  position.  The  dorsal  or  lateral  decubitus  is  requisite  to 
explore  thoroughly  the  fundus  or  sides  of  the  womb,  and  also  to  cause  thp 
foetus  to  fall  from  either  side;  the  thighs  should  also  be  flexed,  or  extended, 
according  to  the  region  examined.  The  unaided  ear  will  answer,  but  the 
stethoscope  should  generally  be  employed ;  for,  by  using  it,  the  sounds 
detected  can  be  more  readily  limited,  and  the  abdominal  parietes  more 
easily  depressed  so  as  to  approach  nearer  to  the  foetus;  besides,  many 
females  object  to  the  accoucheur  thus  applying  his  head  flat  on  the  abdomen. 
Experience  has  likewise  convinced  me  that,  when  the  unassisted  ear  is  used, 
the  clearness  of  the  sensations  is  singularly  diminished  by  the  frictions 
which  the  respiratory  movements  of  the  abdomen  make  against  the  ear. 
When  used,  the  enlarged  extremity  of  the  instrument  should  be  deprived 
of  its  mouth-piece,  and  its  whole  circumference  be  exactly  placed  over  the 
region  to  be  ausculted. 

It  is  also  advisable  that  the  woman  lie  on  a  bed  of  sufficient  height,  other- 
wise the  accoucheur  is  obliged  to  stoop  too  much,  and  this  inconvenient 
position  is  attended  by  such  a  degree  of  congestion  as  to  render  it  impos- 
sible to  hear  anything.  And  further,  to  avoid  all  unnecessary  searching,  it 
is  best  to  place  the  stethoscope  at  first  directly  over  the  part  where  the 
pulsations  of  the  heart  are  most  commonly  heard,  that  is,  in  front,  below, 
and  a  little  to  the  left  side.  « 

It  is  equally  desirable  to  ascertain  from  the  female  where  she  generally 
perceives  the  foetal  movements,  for  most  frequently  the  pulsations  of  the 
heart  will  be  found  on  the  opposite  side,  because  the  superior  and  inferior 
extremities  being  always  folded  on  the  abdominal  plane,  the  back,  in  other 
words,  the  part  of  the  foetus  which  most  easily  transmits  the  sounds,  will 
evidently  be  turned  towards  the  left,  if  the  right  side  is  the  habitual  seat 
of  the  active  motions. 

Before  the  fifth  month,  the  pulsations  are  usually  perceived  in  the  lower 
part  of  the  abdomen  on  the  median  line,  about  half-way  between  the  pubis 
and  umbilicus ;  consequently  the  instrument  should  be  first  applied  tnere. 

The  instrument  proposed  by  Nauche,  under  the  name  of  metroscope,  the 
extremity  of  which  is  intended  to  be  introduced  into  the  vagina  and  applied 
to  the  neck  or  inferior  part  of  the  woiab,  ought  not  to  be  used. 


266 


PREGNANCY. 


A  Table  exhibiting  the  Signs  of  Pregnancy  at  various  Periods. 


RATIONAL    SIGNS. 


SENSIBLE    SIGNS. 


First  and  Second  Months. 


1.  Suppression  of  the  menses  (numerous     1.  Augmentation  in  the    size  and    weight 

of  the  uterus. 

2.  Descent  of  the  organ. 

3.  The  womb  is  less  movable. 

4.  Its  walls  have  the  consistence  of  caout- 
chouc. 

5.  The  neck  is  directed  downwards,  for- 
wards, and  to  the  left. 

C.  The  body  becomes  more  globular  and 
feels  elastic  to  bimanual  palpation. 

7.  The  oritice  of  the  os  tiucoe  is  rounded 
in  primiparae,  but  more  patulous  in 
others  who  have  had  children. 

8.  A  slight  softening  of  the  mucous  mem- 
brane covering  the  lips,  and  this  mem- 
brane appears  cedematous. 

Third  and  Fourth  Months. 


exceptions 

2.  Nausea  —  vomiting. 

3.  Slight  flatness  of  the  hypogastric  region. 

4.  Depression  of  the  umbilical  ring. 

6.  Tumefaction  of  the  breasts,  accom- 
panied with  sensations  of  pricking  and 
tenderness. 


Suppression  of  the  menses  (a  few  excep- 
tions). 


1.  The  fundus  uteri  rises  to  the  level  of  the 
superior  strait  towards  the  end  of  the 
third  month,  and  is  perceived  at  the 
close  of  the  fourth  about  the  middle  of 
the  space  between  the  umbilicus  and 
pubis. 

2.  A  perceptible  flatness  on  percussion  in 
the  hypogastric  region. 

3.  A  rounded  tumor,  as  large  as  a  child's 
head  of  a  year  old,  may  be  detected  by 
the  abdominal  palpation. 

4.  By  resorting  to  this  process  and  the 
vaginal  touch  jointly,  the  displacement 
en  masse,  and  the  volume  of  the  uterus 
may  easily  be  ascertained. 

5.  The  neck  has  the  same  situation  and 
direction  during  the  third  month  as  in 
the  preceding  ones;  at  the  (uirth  it  is 
elevated  and  directed  backwards  and  to 
the  left.  side. 

G.  The  softening  of  the  periphery  of  the 
orifice  is  much  better  marked.  The  lat- 
ter is  more  open  in  multipara,  even  ad- 
mitting the  extremity  of  the  finger ;  but  is 
closed  and  always  rounded  in  primiparae. 
Fifth  and  Sixth  Months. 
1.  Suppression  of  the    menses  (some  rare     1.   The  fundus  uteri  is  one  finger's  breadth 


2.  Frequently,  the  appearance  or  the  con- 
tinuance of  the  vomitings. 

3.  A  small  protuberance  in  the  hypogas- 
tric region. 

4.  Less  depression  of  the  umbilical  cica- 
trix. 


A  ugmented  swelling  of  the  breasts,  pro- 
minence of  the  nipple,  and  slight  dis- 
coloration in  the  areola. 


6.  Xyesteine  in  the  urine. 


exceptions). 


2.  The  disturbances  in  the  digestive  organs 
generally  disappear. 

3.  Considerable  development  of  the  whole 
sub-umbilical  region. 


below  the  umbilicus  at  the  end  of  the 
fifth  month;  and  the  same  distance 
above  it  at  the  expiration  of  the  sixth. 
Foetal  irregularities,  and  active  move- 
ments, which  are  very  perceptible. 
The  sound  of  the  heart  and  abdominal 
sMiillle  are  now  perceptible. 


DIAGNOSIS    OF    PREGNANCY. 


267 


RATIONAL    SIGNS 

A  convex,  fluctuating,  rounded  abdomi- 
nal tumor,  salient,  particularly  on  the 
middle  line,  and  sometimes  exhibiting 
the  foetal  inequalities. 
The  umbilical  depression  is  almost  com- 
pletely effaced. 


6.  The  discoloration  in  the  areola  is 
deeper;  glandiform  tubercles;  areola 
spotted. 

7.  Kvesteine  in  the  urine. 


SENSIBLE     SIGNS. 

4.  Ballottement. 


A  tumor  is  felt  at  the  anterior  superior 
part  of  the  vagina,  which  is  sometimes 
soft  and  fluctuating,  at  others  rounded, 
hard,  and  resisting. 
The  inferior  half  of  the  intra-vagina1 
portion  of  the  cervix  uteri  is  softened 

The  whole  ungual  part  of  the  first  pha- 
langeal bone  can  penetrate  the  cavity 
of  the  neck  in  multiparse.  The  latter  is 
softened  to  the  same  extent  in  prinii- 
parse,  but  the  orifice  is  closed. 


Seventh  and  Eighth  Months. 


1.  Suppression  of  the  menses  (the  excep- 
tions are  very  rare). 

2.  Disorders  of  the  stomach  (rather  rare). 


3.  The  abdominal  tumor  has  the  same 
characters,  except  that  it  is  more  volu- 
minous. 

4.  A  complete  effacement  of  the  umbilical 
depression,  the  dilatation  of  the  ring, 
and  sometimes  a  pouting  of  the  navel. 

5.  Numerous  discolorations  on  the  skin  of 
the  abdomen. 

C.  Sometimes  a  varicose  and  ©edematous 
condition  of  the  vulva  and  inferior  ex- 
tremities. 


1.  Increased  size  of  the  abdomen. 

2.  The  fundus  uteri  is  four  fingers' breadth 
above  the  umbilicus  at  the  seventh 
month,  and  five  or  six  at  the  eighth. 

3.  The  organ  is  nearly  always  inclined  tc 
the  right. 

4.  More  violent  active  movements  of  the 
foetus. 

5.  Sounds  of  the  heart  and  abdominal 
souffle. 

6.  Ballottement  is  very  evident  during  the 
seventh  month,  but  more  obscure  in  the 
eighth. 


7.   Deeper    discoloration    of    the    central     7.  The  softening  extends  along  the  neck. 


areola,  and  an  extension  of  the  spotted 
areola.  Sometimes  there  are  numerous 
stains  on  the  breasts;  flow  of  milk  ;  com- 
plete development  of  the  glandiform 
tubercles. 


8.  Persistence  of  kyesteine  in  the  urine. 


above  the  vaginal  insertion.  In  primi- 
parae,  the  cervix  is  ovoid,  and  seems  to 
have  diminished  in  length;  in  others  it 
is  conoidal,  the  base  being  below,  and 
sufficiently  patulous  to  admit  all  the  first 
phalanx.  The  neck  at  its  superior  fourth 
is  still  hard  and  shut  up. 


First  Fortnight  of  the  Ninth  Month. 


1.   The  vomitings  frequently  reappear. 


1.  The  fundus  uteri  reaches  the  epigastrio 
region  and  gains  the  border  of  the  false 
ribs  on  the  right  side. 

2.  Active  movements.  Sounds  of  the  heart 
and  abdominal  souffle. 

3.  Often  there  is  no  proper  ballottement, 
but  merely  a  kind  of  rising  of  the  tumor 
formed  by  the  head. 

4.   All  the  other  symptoms  persist,  ana  are     4.  The   neck   is   softened   throughout   its 
increased  in  intensity.  whole  length,  excepting  the  circumfer- 

ence of  the  internal  orifice,  which  still 


2.  The  abdominal  tumor  has  increased  ;  the 
skin  is  much  stretched,  and  very  tense. 

3.  Difficulty  of  respiration. 


26S 


PREGNANCY. 


KATIOKAL    SIGNS. 


Last  Fortnight  of 

1.  Tbe  vomitings  often  cease. 

2.  The  abdomen  is  fallen. 

3.  The  respiration  less  oppressed. 

4.  More  difficulty  in  walking. 

5.  Frequent  and  ineffectual  desires  to  uri- 
nate. 


8ENSIBLE    SIGNS. 

remains  closed  and  resisting.  In  won.cn 
who  have  previously  borne  children,  th* 
finger  may  be  introduced  into  the  cervix 
to  the  extent  of  a  phalanx  and  a  half, 
and  in  fact  is  only  arrested  by  the 
internal  orifice,  which  is  closed  and 
wrinkled,  though,  in  some  cases,  already 
beginning  to  open.  In  primiparae,  the 
softening  is  equally  extensive,  and  tbe 
neck  is  swollen  in  the  middle  in  an 
ovoidal  form  ;  but  the  external  orifice, 
although  partially  opened,  does  not  per- 
mit the  introduction  of  a  finger. 

the  Ninth  Month. 

1.  The  fundus  uteri  has  sunk  lower  than 
in  the  first  fortnight. 

2.  Active  movements ;  sounds  of  the  heart 
and  bellows  murmur. 

3.  Ballottement  often  imperceptible. 

4.  The  head  more  or  less  engaged  in  the 
excavation. 

5.  In  multipara,  the  internal  orifice  softens 
and  dilates;  the  finger  can  then  pene- 
trate through  a  cylinder,  as  it  were,  an 
inch  and  a  half  in  length,  and  come  into 
contact  with  the  naked  membranes.  In 
primiparse,  the  internal  orifice  experi- 
ences the  same  modification,  but  the 
external  remains  closed.  During  the 
last  week,  in  consequence  of  the  spread- 
ing out  at  the  internal  orifice,  the  whole 
cavity  of  the  neck  becomes  confounded 
with  that  of  the  body,  and  the  finger,  in 
reaching  the  membranes,  only  traverses 
a  thin  orifice  in  primipara).  but  a  round- 
ed collar  in  the  others  of  a  variable 
thickness. 


6.  Hemorrhoids ;  augmentation  of  the 
oedema  and  varicose  state  of  tbe  lower 
extremities. 

7.  Pains  in  the  loins,  and  colics. 


OF   TWIN    PREGNANCY.  2G9 


CHAPTER    VII. 

OF   TWIN   PREGNANCY. 

The  term  compound  or  multiple  pregnancy  has  been  applied  to  that  in 
which  two  or  more  foetuses  are  inclosed  in  the  uterine  cavity.  Certain 
females  seem  to  be  greatly  disposed  to  these  anomalies  ;  thus,  cases  are 
recorded  where  six,  seven,  and  even  eleven  children  have  been  born  at  three 
successive  confinements. 

Double  pregnancies  are  quite  frequent:  that  is,  one  case  is  met  with  in 
about  seventy  or  eighty  labors.  Triplets,  on  the  contrary,  are  very  rare, 
since  there  were  but  five  in  the  records  of  37,441  accouchements  that 
occurred  at  La  Maternite  in  Paris.  Further,  we  cannot  call  in  question 
those  instances  in  which  there  were  said  to  be  four  at  a  birth  ;  for  such  men 
as  Viardel,  Mauriceau,  Hamilton,  and  many  others,  furnish  examples  of  it.1 
Both  Peu  and  Lauverjat  declare  that  they  have  witnessed  cases  of  five  at  a 
birth.2     And  lastly,  must  we  consider  those  cases  of  six,  seven,  eight,  and 

1  The  following  statistical  account  is  extracted  from  Churchill's  work.  In  161,042 
pregnancies,  there  were  2477  cases  of  twins,  or  1  in  69,  and  36  triplets  do.,  or  1  in 
4473  (English  accoucheurs). 

In  36.570  pregnancies,  there  were  582  cases  of  twins,  or  1  in  110,  and  6  triplets,  or 
1  in  6095  (French  accoucheurs). 

In  251, 386  pregnancies,  there  were  2967  cases  of  twins,  or  1  in  84,  and  35  triplets,  or 
1  in  7186  (German  accoucheurs). 

Total,  in  448,998  cases,  there  were  5776  instances  of  twins,  being  1  in  77f,  and  77 
triplets,  or  1  in  5831. 

The  same  author  furnishes  the  accompanying  information  as  to  the  sex  of  the  twins: 
Dr.  Joseph  Clarke  states,  that  in  184  twin  cases,  both  children  were  boys  47  times, 
girls  68  times,  and  one  boy  and  one  girl  71  times. 

Dr.  Collins  reports  240  cases,  in  which  there  were  two  males  73  times,  two  females 
67  times,  and  male  and  female  97  times  ;  and  Dr.  Lever  33  cases,  two  males  11,  two 
females  11,  and  male  and  female  11. 

8  M.  Pigne"  informed  me  that  he  saw  a  single  placenta  at  Strasbourg,  from  which 
five  separate  cords  arose,  although  only  a  single  sac  existed,  which  was  composed  of 
three  membranes,  decidua,  chorion,  and  amnion,  in  which  the  five  embryos  were  in- 
closed. 

Dr.  Kennedy  [London  Med.  Gazette)  presented  to  the  Royal  Society  the  history  of  a 
woman  who  aborted  at  three  months  of  five  embryos.  There  were  three  ovums,  on" 
being  double,  and  each  ovum  had  a  placenta  and  its  own  proper  membrane. 

M.  Bourdois  (Oaz.  Mid.,  p.  569,  1850)  describes  a  quadruple  pregnancy,  in  which 
the  delivery  occurred  at  the  seventh  month.  The  second  child  was  born  twelve  hours 
after  the  first,  and  the  other  two  a  few  minutes  subsequently.  The  second  accouche 
inent  was  attended  by  a  new  discharge  of  waters;  there  were  two  placentas,  one  of 
which  had  three  cords  and  was  adherent,  and  some  portions  of  it  remained  behind  in 
the  uterus. 

Dr.  Hull,  of  Manchester,  deposited  five  little  twin  foetuses  in  the  Museum  of  the 
London  College  of  Surgeons,  that  he  had  obtained  from  a  woman  who  aborted  at  the 
fifth  month  of  gestation. 

Chambon  records  an  instance  of  quintuple  pregnancy,  where  the  children  survived 
their  baptism. 

A  woman  of  Naples  was  delivered  of  five  infants  at  seven  months.  (British  ana 
Foreign  Med.  Review,  1839.) 

Dr.  Kennedy  (Every)  states  (in  the   Dublin  Med.  Journal,  Jan.  18401,  that  a  woman 


27u 


I'KEGN'ANCY. 


nine  cmldren,  or  even  more,  at  once,  so  many  examples  of  which  are  found 
in  the  authors,  as  true  statements  or  as  fabulous  tales? 

It  is  a  very  difficult  matter  to  point  out  the  causes  of  this  anomaly  in  the 
present  state  of  our  science;  true,  numerous  explanations  have  been  offered, 
but  all  are  nothing  more  than  pure  hypotheses:  for  example,  it  is  said 
that  a  single  fecundation  may  affect  both  ovaries,  or  two  of  the  Graafian  ve=i- 
cles  in  the  same  ovary ;  and  again,  that  several  impregnations  may  occiil 
successively  in  a  short  period,  that  is,  before  the  first  fecundated  ovu'^e  has 
arrived  in  the  uterus.  Both  take  it  for  granted  that  two  ovules  are  de- 
tached, either  at  the  same  time  or  successively,  from  the  ovary,  and,  conse- 
quently, that  two  corpora  lutea  are  developed.  Several  well-attested  facts 
prove,  however,  that  a  different  state  of  things  may  take  place ;  thus,  for 
instance,  two  ovules  have  sometimes  been  found  in  the  same  Graafian  vesicle, 
and  it  is  evident  that  the  rupture  of  this  vesicle  alone,  in  such  a  case,  might 
produce  a  double  fecundation  ;  at  other  times,  two  yolks  have  been  seen  in 
the  same  ovule,  and  in  such  a  condition  a  twin  pregnancy  might  certainly 
occur,  although  but  one  ovule  be  fecundated. 

Hereafter  we  shall  see,  that  these  peculiarities  serve  to  explain  the  varied 
disposition  exhibited  by  the  membranes  be  compound  gestations. 

It  is  frequently  possible  to  recognize  the  presence  of  twins  during  preg- 
nancy ;  indeed,  the  abdomen  is  ordinarily  more  voluminous  then  than  at 
other  times,  and  the  belly  is  generally  flattened  on  the  median  line,  instead 
of  presenting  there  a  well-marked  protuberance ;  the  middle  is  depressed, 
in  consequence  of  the  two  children  lying  one  upon  each  side ;  nevertheless, 
this  sign  may  fail  when  one  child  happens  to  be  placed  before  the  other. 

The  form  of  the  uterus  varies  also  with  the  position  of  the  foetuses,  their 
number,  and  the  amount  of  amniotic  fluid.  Thus,  when  the  head  of  one  is 
above,  and  that  of  the  other  below,  there  may  result  therefrom  two  corre- 
sponding depressions  and  projections,  as  M. 
Hergott  has  represented.  Should  both  pre- 
sent by  the  head,  the  fundus  of  the  womb 
will  be  very  much  dilated,  and  the  contrary 
is  the  case  when  they  present  by  the  pelvis. 
In  a  case  which  occurred  at  the  Clinic  of 
Strasbourg,  the  shape  of  the  womb  was 
irregular  and  oblique;  the  two  heads  occu- 
pied the  angles  of  the  uterus,  and  formed 
two  tumors  separated  by  a  depression  ;  the 
one  at  the  right  being  much  the  higher. 
The  twins  were  born  by  the  feet. 

The  slight  blows  perceived  by  the  mother 
are  sometimes  felt  at  one  and  the  same  time 
in  two  distant  parts  of  the  abdomen ;  and 
the  importance  of  auscultation  as  an  ele- 
ment in  this  diagnosis  has  already  been 
pointed  out.     (See  p.  256.) 

aborted  of  five  embryos  between  the  second  and  third  months  of  gestation  ;  and  finally, 
Dr.  Francis  Humsbotham  has  collected  three  cases  of  quintuple  pregnancy  from  the 
public-  journals. 


Fio.  73. 


OF    TWIN     PREGNANCY.  271 

The  bellows  murmur  can,  I  think,  rarely  furnish  useful  iuformation. 
Still,  it  is  asserted  by  Hohl,  that  in  sixteen  twin  pregnancies,  the  murmur 
was  heard  seven  times  on  both  the  right  and  left  sides  simultaneously,  and 
nine  times  on  one  side  only ;  and  he  affirms,  that  when  the  latter  was 
the  case,  there  was  a  common  placenta,  whilst  in  the  other  instances  {hero 
were  two.  He  is  also  of  the  opinion,  that  a  double  souffle  is  diagnostic  of 
a  double  pregnancy,  even  though  the  sound  of  the  heart  be  heard  at  a 
single  point  only.  We  cannot  admit  the  last  conclusion,  since  we  have 
already  denied  the  very  relation  which  Hohl  would  establish  between  the 
6eat  of  the  murmur  and  the  insertion  of  the  placenta;  besides  which  we  have 
often  heard  a  souffle  on  both  the  right  and  left  sides  in  single  pregnancies. 

Again,  as  the  two  foetuses  mutually  interfere  with  each  other,  neither  of 
them  presents  itself  to  the  vaginal  touch ;  and  of  course  the  ballottement 
is  then  exceedingly  difficult,  if  not  wholly  impossible ;  for,  even  if  the 
finger  should  easily  reach  the  presenting  part,  the  presence  of  another 
child  would  interfere  with  the  ascending  movement  of  the  first.  Desor- 
meaux,  however,  cites  a  case  where  the  ballottement  was  manifest  in  a  twin 
gestation,  but  even  here  a  large  quantity  of  water  was  present  at  the  same 
time.  Whilst  in  charge  of  the  Clinic  of  the  Faculty,  in  1845,  I  observed 
on  two  occasions  the  same  fact  noticed  by  Desormeaux ;  for  the  existence 
of  dropsy  of  the  amnion  rendered  the  ballottement  very  perceptible,  although 
two  children  were  present. 

The  course  of  twin  pregnancies  is  sometimes  accompanied  by  peculiar- 
ities which  it  is  important  to  be  acquainted  with.  Thus,  the  two  foetuses 
do  not  always  attain  to  the  development  which  we  have  indicated.  One  of 
them  may  die,  and  yet  the  other  continue  to  grow.  In  such  cases,  which, 
however,  are  rare,  the  dead  body  may  remain  in  the  womb,  where  it  hardens, 
withers,  and  is  expelled  during  labor. 

In  my  course  of  1853,  I  exhibited  a  placenta  obtained  from  a  woman 
who  was  delivered  at  term  of  a  living  and  well-developed  child.  It  was 
provided  with  two  amniotic  bags,  one  of  which  belonged  to  the  living 
child,  and  presented  no  unusual  appearance.  The  other,  which  was  much 
smaller,  contained  barely  a  trace  of  fluid,  but  inclosed  a  small  mummy- 
like foetus,  about  the  size  of  one  of  four  months'  development.  On  the 
other  hand,  the  dead  foetus  may  irritate  the  uterus,  bring  on  contractions, 
and  be  expelled,  whilst  the  other  remains  and  is  developed  as  usual. 

Lastly,  the  twin  that  perished  during  pregnancy  may  still  remain  in  the 
womb,  in  consequence  of  the  adherences  which  its  placenta  has  contracted 
with  that  organ,  for  a  long  period  after  the  expulsion  of  its  living  brother, 
that  occurs  at  the  ordinary  term  of  gestation. 

Guillemot  furnishes  one  of  the  most  curious  observations  of  this  kind 
(Heureux  Ace,  livre  ii.  p.  225)  on  record,  in  which  the  artificial  extraction 
of  the  dead  body  did  not  take  place  until  two  years  after  the  accouche- 
ment. But  what  is  the  cause  which  thus  determines  the  death  of  one 
foetus  ? 

Mauriceau  and  Peu  thought  it  might  be  attributed  to  the  fact  that  one 
child,  by  receiving  all  the  nourishment,  becomes  strong  and  vigorous  at  the 
expense  of  the  other,  thereby  rendering  it  feeble  and  languishing,  and 
causing  its  early  death. 


272  PREGXAXCY. 

M.  Guillemot  believes  that  one  child,  in  its  growth,  gradually  compresses 
f  he  second  against  the  uterine  wall,  and  the  latter,  not  having  sufficient 
Pliace  for  its  development,  soon  after  dies.  Lastly,  M.  Cruveilhier  explains 
(he  atrophy  of  the  foetus  by  a  gradual  separation  of  the  placenta,  founding 
his  opinion  on  a  single  case,  in  which  the  hemorrhage  was  great  enough  to 
account  for  the  early  death  of  one  of  the  twins ;  but  in  the  greater  number 
of  cases  that  have  been  recorded,  no  mention  whatever  is  made  of  any 
hemorrhage  during  the  pregnancy ;  whence,  of  course,  the  opinion  of  M. 
Cruveilhier  would  not  be  applicable  to  them.  For  my  own  part,  I  believe 
these  cases,  in  which  the  death  and  atrophy  of  one  foetus  takes  place,  should 
rather  be  attributed  to  some  disease  of  the  infant  or  placenta,  or  of  some 
parts  of  its  envelopes.  It  may  be  urged,  indeed,  that  these  alterations  are 
not  observed  at  the  time  of  accouchement,  which  is  not  to  be  wondered  at, 
considering  the  state  of  degeneration  exhibited  by  all  parts  of  the  ovum ; 
and,  although  no  positive  fact  sustains  this  opinion,  it  seems  to  me  more 
admissible  and  more  rational  than  the  others. 

It  not  unfrequently  happens  that  twin  pregnancies  terminate  before  full 
term,  owing,  doubtless,  to  the  great  distention  of  the  uterus,  which  is  often 
as  large  at  seven  or  eight  months  as  in  a  simple  pregnancy  at  nine  months. 
The  same  labor  generally  suffices  for  the  expulsion  of  both,  though  such  is 
not  always  the  case ;  for,  after  the  first  child  is  born,  the  uterus  may  re- 
traci,  upon  the  remaining  twin,  and  leave  it  unexpelled  for  eighteen  or 
twenty-four  hours.  A  still  longer  interval,  several  months  even,  may 
separate  the  two  parturitions ;  and  it  is  upon  such  facts  as  these  that  some 
persons  have  improperly  admitted  the  doctrine  of  superfoetation.  A  refer- 
ence to  the  latter  is,  however,  unnecessary  to  explain  these  observations,  for 
the  cause  of  premature  delivery  is  dependent  solely  on  the  enormous  dis- 
tention of  the  uterus,  because  as  soon  as  one  infant  is  expelled  the  womb 
retracts,  the  cause  of  irritation  no  longer  exists,  and  we  can  readily  con- 
ceive that  the  gestation  may  continue  on  until  term.  A  child  born  at  seven 
months  may  live  equally  well  with  one  delivered  at  the  end  of  preg- 
nancy. 

The  peculiarities  just  studied  in  twin  pregnancies  may  also  present 
themselves  in  cases  of  triplets,  &c.  Thus,  in  a  case  cited  by  Port?'.,  after 
the  delivery  of  the  first  child  and  its  placenta,  which  were  healthy,  he  was 
obliged  to  extract  two  others  that  had  apparently  been  dead  for  a  long 
time,  and  were  thoroughly  dried. 

Again,  the  membranes  are  not  always  disposed  in  the  same  manner  in 
these  pregnancies ;  and  on  this  head  we  may  admit,  with  M.  Guillemot,  who 
has  particularly  studied  the  subject,  four  distinct  varieties:  thus,  in  the 
first,  two  ovules  are  fecundated,  and  each  embryo  becomes  developed,  and 
is  surrounded  by  its  own  proper  membranes;  in  the  second,  the  ovule  con- 
tains two  germs,  though  each  foetus  has  but  a  single  envelope,  the  chorion 
being  a  common  membrane;  in  the  third,  both  embryos  are  inclosed  in  a 
single  cavity,  which  appears  never  to  have  been  divided  by  any  membranous 
diaphragm ;  and,  finally,  the  last  variety  is  met  with  when  the  ovule  con- 
tains a  second  germ,  and  both  become  developed  together,  which  gives  rise 
to  what  are  called  monstrosities  by  inclusion.     Adopting  this  classification 


OF    TWIN    PREGNANCY.  273 

as  the  basis,  let  us  now  proceed  to  the  different  modes  of  termination 
presented  by  these  pregnancies,  according  to  the  species  to  which  they 
belong. 

1.  In  the  first  variety,  both  ovules  are  developed,  retaining  their  proper 
membranes,  the  chorion  and  amnion  ;  at  first,  each  ovum  has  its  own  re- 
flexed  decidua,  but  generally  that  portion  of  the  latter  which  forms  the 
partition  is  very  thin,  and  becomes  absorbed  as  the  gestation  advances,  and 
a  single  decidua  then  appears  to  envelop  both. 

The  two  chorions  repose  against  each  other,  being  only  separated  by 
some  very  fine  areolar  tissue,  so  that  the  children  are  divided  by  one  very 
thick  partition  composed  of  four  layers.  The  placentas  are  sometimes 
separate,  though  usually  confounded  with  each  other,  or  else  are  united  by 
a  kind  of  membranous  bridge;  but,  notwithstanding  the  continuity  of 
tissue,  there  rarely  exists  any  vascular  communication  between  them,  and 
this  fact  is  so  uniform  that  the  exceptions  to  the  law  are  very  rare  indeed. 
From  all  which  it  must  therefore  be  evident  that  two  distinct  ovules  have 
been  fecundated,  whether  they  are  deposited  separately,  or  are  contained  in 
the  same  vesicle.     The  first  variety  is  the  most  frequent. 

2.  In  the  second  variety  of  compound  pregnancy,  the  chorion  is  common 
to  both  twins,  and  each  foetus  has  but  a  single  envelope  formed  of  the  am- 
nion— the  two  lamina?  of  which,  resting  against  each  other,  constitute  the 
median  partition.  MM.  Dance  and  Mancel  have  furnished  an  example  of 
this  variety  in  which  there  were  but  two  children.  Brendelius  reports  that 
a  woman  was  delivered  of  two  girls  after  three  days'  travail,  but  she  died 
before  the  extraction  of  the  third  infant,  which  was  found  dead  on  opening 
her  body  ;  the  placenta  was  single  and  very  large,  and  the  chorion  had  been 
common  to  all  three,  although  each  foetus  had  a  distinct  amnion. 

There  is  therefore  only  a  single  placenta,  and  a  communication  nearly 
always  exists  between  the  ramuscules  of  the  two  cords,  as  I  have  verified 
myself,  on  a  placenta,  which  was  presented  by  one  of  my  former  pupils,  an 
Interne  of  the  Ursuline  Hospital,  where  he  obtained  it.  In  this,  as  in  the 
preceding  variety,  one  foetus  may  die,  the  other  continuing  to  live;  but  it  is 
easily  foreseen  that  an  expulsion  of  the  two  children  cannot  take  place 
separately. 

3.  Further,  it  may  happen  that  the  foetuses  are  not  separated  by  any 
partition,  and  are  all  shut  up  in  the  same  amniotic  cavity;  and  to  the  ex- 
amples of  this  kind,  already  cited,  I  may  add  a  case  observed  by  my  friend 
and  colleague,  Dr.  Founder.  The  two  cords  arise,  most  frequently  at  least, 
from  a  distinct  point  of  the  placenta  ;  but  sometimes  they  are  observed  to 
come  from  a  common  trunk,  which  bifurcates  at  a  variable  distance  from 
the  placental  surface.  In  this  variety,  the  expulsion  of  one  foetus  must 
evidently  be  followed  by  that  of  the  other;  but  I  do  not  know  to  what  ex- 
tent we  can  justly  say  that  the  death  of  one  necessarily  endangers  the  other's 
life,  if  not  speedily  delivered  by  nature.  (Baudelocque.)  This  inclusion 
of  two  foetuses  in  the  same  amniotic  cavity  is  often  met  with  in  those  cases 
where  one  of  them  is  destitute  of  an  important  part  of  its  body:  thus,  the 
monstrosity  that  I  presented  to  the  Royal  Academy  of  Medicine  was  in- 
'dofeed  in  the  same  sac  with  its  twin  brother. 

18 


274 


PREGNANCY. 


But  it  is  nearly  or  wholly  impossible,  in  the  present  state  of  ovological 
knowledge,  to  explain  this  strange  anomaly,  the  existence  of  which,  how- 
ever, has  several  times  been  clearly  verified. 

In  accordance  with  what  we  have  said  respecting  the  formation  of  the 
amnion  (see  Art.  Otology),  this  membrane  emanates  from  the  embryo  itself, 
and  consequently  the  amniotic  membranes  should  equal  the  foetuses  in  num- 
ber; but,  without  admitting  the  theory  of  Pockels  and  Serres  on  the  devel- 
opment of  the  amnion,  a  theory  which,  notwithstanding  its  want  of  proba- 
bility, derives,  from  the  facts  alluded  to,  a  certain  degree  of  support,  we 
cannot  explain  them  but  by  supposing  that  two  amniotic  membranes  existed 
primitively,  and  that  the  partition  produced  by  their  contact  has  been  some- 
how destroyed.  Most  generally,  there  are  numerous  communications  exist- 
ing between  the  umbilical  ramifications,  as  we  have  stated,  when  the  cho- 
rion, and  especially  the  amnion,  are  common  to  both,  which  is  not  always 
the  case.  Thus,  Dodd  reports  a  case  of  triplets,  where  the  placentas  wen' 
consolidated  into  one,  two  of  the  children  being  inclosed  in  a  common  cho- 
rion, whilst  the  third  had  a  special  one;  the  umbilical  vessels  did  not  com- 
municate with  each  other.  In  another  instance,  recorded  by  Davis,  the 
three  foetuses  had  a  common  decidua ;  two  of  them  were  surrounded  by  the 
same  chorion  and  amnion,  but  the  third  had  its  chorion  and  amnion  distinct 
from  the  others ;  the  placenta  formed  a  single  mass,  bui  the  vessels  had  no 
communication  with  each  other.      {London  Med.  Gazette,  1841.) 

4.  Finally,  the  fourth  variety  of  compound  pregnancy  that  we  have 
admitted,  along  with  M.  Guillemot,  constitutes  what  has  been  called  a  mon- 
strosity by  inclusion.  It  consists  of  the  complete  inclusion  of  the  elements, 
whether  more  or  less  numerous,  of  one  foetus  in  the  body  of  another  foetus, 
which  is  otherwise  well  formed. 

Table  for  Calculating;  the  Period  of  Utero-Gestation.  (Smith.) 


NINE  CALENDAB  MONTHS 

TEN    LUNAR   MONTHS 

FROM 

TO 

DWS. 

TO 


DATS. 

January    1    .      .     .     . 
February  1 .      .      .      . 

July  1 

\  li  g MSt   1 

September  1 
October  1     .     .     .     . 
November  1       .     .     . 
December  1      .     .     . 

September  30   .     .     . 
October  31  ...     . 
November  30    .      .      . 
December  31 

February  28 

March  31     ...     . 

April  30 

May  31 

June  30 

August  31     ...     . 

273 

273 
275 
275 
276 
273 
274 

273 
273 
273 
274 

October  7     .     .     .     . 

November  7      .     .     . 

1    December  5       ... 

'   February  4 .     .     .     . 

May  7 

August  7      .     .     .     . 
September  6 

280 

280 
280 
280 
280 
280 
280 
■j  SI) 

•j  so 
280 
280 

280 

Explanation. — The  above  obstetric  "Ready  Reckoner"  consists  of  two  columns, 
one  of  calendar,  the  other  of  lunar  months,  and  may  be  read  as  follows:  A  patient 
has  ceased  to  menstruate  on  July  1  ;  her  confinement  may  be  expected  at  soonest  about 
March  31  {the  end  of  nine  calendar  months)  ;  or  at  latest  on  April  6  [at  the  end  of  ten  lunar 
months).  Another  has  ceased  to  menstruate  on  January  20  :  her  confinement  mny  be 
expected  on  September  30,  plus  20  days  (the  end  of  nine  calendar  months)  at  soonest  ;  or 
on  October  7,  plus  20  days  (the  end  often  lunar  month*)  at  latest.     (Playfair.) 


PAET  III. 
OF  LABOR. 

LABOR  is  that  function  which  consists  in  the  spontaneous  or  artificial 
expulsion  of  a  viable  foetus  through  the  natural  parts  of  generation.  The 
term  labor  is  used  more  especially  to  designate  the  expulsion  of  the  child ; 
the  expulsion  of  the  placenta  being  treated  of  under  the  head  of  Delivery, 
of  that  organ. 

This  definition  of  labor,  differing  as  it  does  somewhat  from  those  given 
by  most  modern  writers,  has  the  advantage  of  furnishing  me  a  basis  whereon 
to  found  a  practical  division  ;  for  when  the  expulsion  of  the  foetus  takes 
place  from  the  efforts  of  nature  alone,  it  is  called  a  spontaneous,  or  a  natural 
labor ;  but  when  nature  is  inadequate  to  the  accomplishment  of  this  effect, 
and  art  is  obliged  to  intervene,  the  delivery  is  said  to  be  artificial,  laborious, 
and  also  (though  improperly)  unnatural. 

This  function  has  also  received  different  denominations,  according  to  the 
period  of  pregnancy  at  which  it  is  manifested :  thus,  it  has  been  named 
legitimate,  timely,  or  at  term,  when  occurring  within  a  week  before  or  after 
the  expiration  of  the  ninth  month.  On  the  contrary,  it  is  called  premature 
or  precocious,  if  it  takes  place  during  the  seventh,  the  eighth,  or  the  begin- 
ning of  the  ninth  month.  Again,  the  latter  may  be  spontaneous  or  artifi- 
cial, according  to  whether  it  is  simply  the  work  of  nature  or  has  been 
brought  on  by  the  intervention  of  art.  This  last  case  should  be  carefully 
distinguished  from  what  the  ancients  called  forced  labor,  in  which  they  not 
only  provoked  the  manifestation  of  the  uterine  contractions  by  a  more  or 
less  direct  irritation,  but  effected  the  delivery  at  once. 

Lastlv,  it  is  called  tardy,  or  retarded,  when  the  delivery  is  not  accom- 
plished before  nine  months  and  a  half  or  ten  months. 

At  whatever  period  delivery  may  occur,  it  is  always  effected  under  the 
influence  of  the  same  forces ;  though  there  is  an  important  distinction  to 
be  established  in  the  phenomena,  constituting  what  practitioners  are  agreed 
to  call  the  labor.  Whenever  we  examine  carefully  the  whole  of  those  phe- 
nomena, we  can  readily  make  out  two  very  distinct  orders  of  facts.  The 
one  is  nothing  more  than  an  expression  of  the  vital  action  brought  into 
pl.iy  for  the  expulsion  of  the  foetus,  while  the  other  is  constituted  of  the  suc- 
cessive movements  which  the  child  itself  executes  during  such  expulsion  ; 
the  first  is  purely  physiological,  the  second  embraces  the  mechanical  phe- 
nomena of  the  labor.  Though  often  confounded  in  practice,  these  two  orders 
should  be  carefully  distinguished  in  theory. 

We  shall  therefore  have  to  examine,  in  as  many  separate  chapters,  I  he 
causes  and  physiological  phenomena,  as  also  the  mechanical  phenomena 
both  of  labor   p;  rperly  so  called,  and  of  the  delivery  of  the  placenta. 

275 


27()  LABOR. 

Again,  although  in  the  vast  majority  of  cases  the  woman  is  really  able  to 
deliver  herself,  yet  there  are  many  precautions  which  the  accoucheur  should 
bear  in  mind,  and  a  series  of  little  attentions  he  must  give  to  the  patient  it! 
the  course  of  the  parturition  ;  besides,  the  child  will  likewise  require  his 
intelligent  aid,  either  during  the  travail  or  immediately  after  its  birth,  and 
therefore  we  shall  devote  a  chapter  to  the  exposition  of  those  attentions  and 
precautions. 

"We  shall,  in  the  first  place,  enter  upon  the  study  of  natural  labor  at  term, 
spontaneous  premature  delivery,  retarded  labor,  and  natural  delivery  of  the 
after-birth  ;  leaving  the  subjects  of  difficult  labor  and  preternatural  delivery 
of  the  placenta,  to  be  treated  of  hereafter  under  the  head  of  Dystocic. 
Premature  artificial  delivery  will  be  described  in  connection  with  the  other 
obstetrical  operations. 


CHAPTER  I. 

OF   THE   CAUSES   OF   NATURAL   LABOR   AT   TERM. 
These  have  been  divided  into  the  efficient  and  the  determining  causes. 

§  1.  Efficient  Causes. 

For  a  long  time  the  foetus  was  regarded  as  the  principal  agent  of  its  own 
delivery,  and  as  the  chick  breaks  the  shell  of  the  egg,  so  it  was  supposed  to 
effect  the  rupture  of  the  membranes  which  contained  it.  The  advocates  of 
this  opinion,  which  is  no  longer  admitted,  except  by  some  persons  out  of  the 
profession,  relied  chiefly  on  the  fact  of  dead  children  being  expelled  more 
slowly  from  the  womb,  and  with  more  difficulty  than  others;  and  further 
also  because,  in  certain  instances,  the  child  has  been  known  to  escape  from 
the  uterus  some  time  after  the  mother's  death.  But,  in  reality,  these  two 
facts  have  no  value  whatever  in  the  question  before  us ;  for  the  death  of 
the  foetus,  when  recent,  does  not  materially  retard  the  parturition,  and 
writers  were  altogether  in  error  as  to  the  influence  attributable  thereto. 

The  living  infant  is  expelled  more  rapidly,  not  in  consequence  of  being 
the  agent  of  its  own  discharge,  but  because  its  movements  irritate  the  uterus 
and  solicit  its  more  frequent  contractions ;  after  its  death  the  organ  is,  on 
the  contrary,  deprived  of  that  natural  irritant.  Besides,  whenever  the  foetus 
has  been  defunct  for  a  long  time,  another  cause  of  retardation  is  added  to 
the  former;  for  where  the  product  of  conception  has  undergone  a  partial 
decomposition,  the  contractility  of  the  uterine  walls  is  unfavorably  influ- 
enced  thereby.  In  fact,  the  vitality  of  the  organ  seems  to  be  in  relation,  to 
a  certain  extent,  with  that  of  the  inclosed  body  ;  the  blood  being  no  longer 
attracted  thither  by  the  ordinary  stimulus,  does  not  reach  there  in  such 
large  quantities  as  before,  and  consequently  the  greater  vital  activity  usually 
manifested  in  gestation  is  lost;  hence  arise  atony  of  its  walls,  an  excessive 
feebleness  of  its  contraction,  and  slowness  of  the  labor.  Again,  the  fcetal 
trunk,  being  softened  by  the  changes  before  described,  collapses,  as  it  were, 
and  ceases  to  offer  that  resistance  to  the  uterine  wall  which  is  necessary  to  the 


CAUSES     OF     NATURAL     LABOR    AT    TERM.  277 

energy  and  the  maintenance  of  its  contraction.  Therefore,  if  it  be  true 
that  the  death  of  the  infant  renders  its  delivery  more  difficult,  it  is  solely  from 
the  unfavorable  influence  that  this  occurrence  may  have  over  the  exercise 
of  the  organic  contractility. 

Instances  of  children   having  been    delivered   spontaneously  after  the 
mother's  death  are  quite  numerous,  and  this  is  the  strongest  argument 
adduced  by  those  who  believe  that  the  foetus  is  the  principal  agent  in  the 
expulsion.     But  numerous  observations,  among  others  those  related  by  Dr. 
Planque  (in  La  BibliotUque  tie  Medecine  Choisie),  prove  that  those  infants 
were  dead  even  before  the  mother.     Now  these  facts,  extraordinary  as  they 
appear,  can  be  very  naturally  explained  as  follows :  Supposing  the  delivery 
took  place  shortly  after  the  parent's  death,  the  motor  faculty  of  the  uterus 
is  not  so  dependent  on  the  nervous  system  as  to  be  entirely  lost  immediately 
upon  the  cessation  of  vitality  in  the  latter,  and  is  evidently  retained  for 
some  time  after  the  mother  has  succumbed.     Thus,  Leroux  has  observed 
the  uterus  contract  a  quarter  of  an  hour  after  the  last  breath  ;  and  Osiander, 
after  having  performed  the  Cesarean  section  on  a  corpse,  found  the  uterus 
as  much  contracted  the  next  day  as  it  usually  is  in  a  woman  just  after  her 
confinement.     It  is,  therefore,  very  natural  to  suppose  that  such  deliveries 
are  owing  to  the  contractile  action  of  the  womb,  which,  says  Desormeaux, 
it,  like  other  hollow  muscles,  still  preserves  for  some  time  after  death  ;l  and 
finally,  let  us  add,  that  the  real  death  in  many  cases  may  have  been  preceded 
by  an  apparent  one,  and  possibly  that  the  former  may  not  have  occurred 
until  just  at  the  instant  of,  or  immediately  after  the  delivery  took  place. 
But  when  the  expulsion  of  the  foetus  did  not  occur  before  the  lapse  of  two 
or  three  days,  we  must  suppose,  with  M.  Velpeau,  that  the  labor  was  well 
advanced  at  the  time  of  the  mother's  death,  and  gas  being  rapidly  produced 
in  large  quantities  in  the  intestinal  canal,  the  uterus  was  thereby  mechani- 
cally compressed  on  its  exterior,  and  the  ovum   consequently  forced  out 
entire.     Perhaps  the  subjoined  case,  reported  by  Hermann,  might  be  ex- 
plained in  that  way.     (Edin.  Med.  and  Surg.  Journal,  New  Series,  N^  vi 

p.  431.) 

A  young  woman  died  in  her  tenth  month,  and  the  third  day  after,  the 

'  Dr.  Tyler  Smith  states  that  the  reflex  action  may  continue  for  some  time  after  the 
complete  cessation  of  the  respiratory  movements,  and  in  some  cases  be  powerful  enough 
to  effect  the  delivery  when  the  patient  has  died  during  labor ;  but  that,  in  most  instances, 
\hz  post-mortem  expulsion  of  the  foetus  is  due  to  a  peristaltic  contraction  of  the  uterine 
fibres.  We  find  it  difficult  to  admit  the  existence  of  a  vermicular  contraction  powerful 
enough  to  produce  such  a  restdt. 

M.  Brown-Sequard  has  recently  advanced  what  he  regards  as  an  explanation  of  this 
posthumous  contractility.  According  to  this  learned  physiologist,  the  contact  of  venous 
blood  with  the  muscular  fibre  is  sufficient  to  stimulate  it  to  contraction.  I  have 
observed,  he  says,  movements  in  the  uteri  of  recently  killed  animal-,  whose  spinal 
marrow  had  been  destroyed  throughout  its  length.  I  have  seen  these  same  movements 
in  the  uterus  extracted  from  a  living  animal.  These,  which  could  nol  be  attributed  to 
reflex  action,  since  there  was  no  opportunity  for  the  exercise  of  nervous  influence, 
were  due  simply  to  the  contact  of  non-oxygenated  blood,  to  prove  which  he  relates  the 
following  experiment.  The  spinal  marrow  in  two  Guinea-pigs,  which  had  reached 
the  end  of  gestation,  was  destroyed  from  the  sixth  rib  to  the  sacrum,  yet  labor  began 
and  ended  shortly  after  a  ligature  was  drawn  tightly  around  the  trachea. 


278  LABOK. 

attendants  noticed  a  strange  noise  about  the  corpse.  A  physician  was 
hastily  summoned,  who  found  that  twins,  still  inclosed  by  the  intact  mem- 
branes, had  been  just  delivered.  The  children  presented  no  traces  of  putre- 
faction, the  placenta  alone  showing  a  commencing  alteration. 

But.  besides  these,  numerous  other  objections  still  remain  against  this 
theory:  1.  The  delivery  exhibits  nearly  the  same  phenomena,  at  whatever 
period  of  gestation  it  takes  place  ;  now,  can  any  one  suppose  that  the  foetus, 
which  scarcely  moves  at  all  in  the  early  months,  can  at  once  acquire  a 
sufficient  degree  of  strength  to  overcome  the  great  resistance  made  at  that 
time  by  the  uterine  neck?  2.  It  is  well  known,  that,  if  the  child  present 
by  any  other  part  than  the  head  in  labor  at  term,  the  presenting  part  is  so 
high  up,  before  the  rupture  of  the  amniotic  pouch,  that  it  can  in  no  wise 
contribute  to  the  dilatation  of  the  os  uteri.  3.  Again,  the  foetal  efforts  cer- 
tainly ought  to  affect  the  bag  of  waters  first,  and  therefore  a  rupture  of  the 
enveloping  sac  should  always  be  among  the  earliest  phenomena  of  the  labor  ; 
however,  such  a  rupture  often  does  not  occur  until  the  very  last  moments; 
sometimes  even  the  ovum  escapes  entire.  4.  Would  it  be  possible  for  the 
most  healthy  and  vigorous  infant  to  make  any  exertions  strong  enough  to 
surmount  the  resistance  opposed  to  its  delivery  in  some  of  the  instances  of 
tedious  labor?  &c,  &c.  From  all  which  we  may  conclude  that  the  foetus 
has  no  influence  over  its  own  expulsion,  and  that  the  efficient  cause  of  the 
delivery  evidently  belongs  to  the  contraction  of  the  uterine  walls,  aided  by 
that  of  the  diaphragm  and  the  abdominal  muscles. 

Furthermore,  to  be  convinced  that  the  womb  acts  the  principal  part  in 
this  process,  it  is  only  necessary  to  examine  a  woman  during  labor,  and, 
more  especially,  to  introduce  the  hand  into  the  uterus  in  a  case  of  difficult 
version.  It  is  its  contractions  alone  which  generally  produce  the  dilatation 
of  the  os  uteri,  thus  preparing  a  way  for  the  child's  passage ;  and  they  also 
perform  the  most  important  part  in  the  later  periods  of  the  labor.  They  are 
even  capable  of  effecting  the  delivery  themselves.  Thus,  for  instance,  the 
parturition  does  not  the  less  take  place  in  animals,  where  the  belly  is  laid 
open,  and  the  abdominal  walls  thereby  rendered  incapable  of  any  further 
action.  It  also  takes  place  in  women  affected  with  procidentia  uteri,'  as  also 
in  those  who  suffer  from  a  paralysis  of  the  abdominal  muscles,  in  conse- 
quence of  an  affection  of  the  spinal  marrow,  or  some  one  of  the  nervou^ 
centres.  Finally,  the  use  of  anaesthetics  within  certain  limits,  destroys  the 
contractility  of  the  voluntary  muscles,  together  with  the  sensibility  ;  yet  the 
uterine  contractility  remains,  and  the  delivery  is  accomplished.  Ordinarily, 
however,  in  the  second  or  expulsive  stage  of  the  labor,  the  uterine  contrac- 
tion is  assisted  by  the  simultaneous  action  of  the  diaphragm  and  abdominal 
muscles. 

At  the  moment  when  the  head  clears  the  neck  of  the  uterus,  especially 
when  by  pressing  strongly  upon  the  floor  of  the  pelvis  it  distends  the 
perineum,  compresses  greatly  the  lower  part  of  the  rectum  and  neck  of  the 

'According  to  the  report  of  Burdach,  Wimmer  has  actually  known  the  labor  to  take 
place  regularly  in  a  woman  whose  womb  formed  a  tumor  between  her  thighs,  eleven 
inches  long  and  seven  and  a  half  inches  broad;  the  opening  in  which  was  directed 
downwards. 


CAUSES     OF     NATURAL     LABOR     AT     TERM.  270 

bladder,  and  opens  and  dilates  the  vulva,  the  pressure  upon  these  parts  ia 
so  violent  that  instinctively,  not  to  say  involuntarily,  the  woman  exerts 
herself  powerfully,  in  order  to  relieve  herself  as  SQon  as  possible  from  the 
insupportable  sensation.  Thus,  fixing  her  feet  firmly  against  the  foot-board 
of  her  bed,  and  clinging  to  anything  around  that  may  offer  a  solid  resist- 
ance, the  patient  takes  a  full  inspiration,  dilates  her  chest,  and  then,  retain- 
ing the  inhaled  air  in  her  lungs,  she  strongly  contracts  all  the  muscles 
firming  the  abdominal  inclosure.  This  auxiliary  contraction  is  so  evident 
that  nobody  can  doubt  it,  and  authors  only  differ  as  to  the  kind  of  aid  it 
brings  to  the  uterine  forces.  Haller  and  others  considered  the  uterine  con- 
tractions as  being  merely  secondary,  and  attributed  to  the  abdominal 
muscles  the  principal  part  in  the  expulsion  of  the  child ;  thus  they  suppose 
that  the  contraction  of  the  organ  simply  serves  to  support  the  foetal  trunk, 
to  embrace  it  properly  like  a  cylinder,  and  to  prevent  the  great  pressure  of 
the  diaphragm  from  crushing  it  in,  while  at  the  same  time  the  act  of  inspira- 
tion and  the  contraction  of  the  abdominal  walls  force  it  outwards.  But, 
from  the  facts  before  stated,  we  may  judge  of  the  value  of  this  hypothesis. 
True,  in  certain  cases  of  excessive  feebleness  of  the  uterus,  and  of  a  com- 
plete inertia  of  its  walls,  the  abdominal  muscles  have  proved  sufficient  to 
terminate  the  delivery;  yet  how  much  oftener  has  it  happened  that  the 
woman,  exhausted  by  antecedent  disease,  and  left  without  energy  or  strength, 
has  been  unable  to  assist  the  womb  by  any  voluntary  contraction  whatever! 

Again,  some  women  have  been  delivered  during  hysterical  or  epileptic 
fits,  in  a  state  of  total  loss  both  of  feeling  and  movement,  where  evidently 
the  uterine  contraction  alone  could  accomplish  it.  This  harmony  of  action 
is  therefore  useful  but  not  indispensable,  since  the  labor  will  often  terminate 
under  the  sole  influence  of  the  uterine  forces;  but  it  will  be  nearly  always 
impossible  in  cases  of  total  inertia  of  the  organ,  however  powerful  the  con- 
tractions of  the  abdominal  muscles  may  be. 

The  researches  of  Cloquet  and  Bourdon  on  the  physiology  of  the  process 
do  not  warrant  the  supposition  of  any  active  pressure  by  the  diaphragm  on 
the  upper  part  of  the  uterus.  They  have  proved,  in  fact,  that  the  principal 
phenomena  consist  in  a  change  of  the  acts  of  respiration,  and  that  the  object 
of  such  change  is  to  furnish  a  solid  point  of  insertion  to  the  muscles  passing 
from  the  chest  both  to  the  trunk  and  upper  extremities.  When  the  air  has 
penetrated  into  this  cavity,  the  glottis  closes  spasmodically;  the  abdominal 
muscles  begin  to  contract;  they  press  back  the  viscera,  in  the  cavity  of  the 
peritoneum  against  the  diaphragm;  the  latter  contracts  in  turn;  and,  being 
sustained  above  by  the  resistance  from  the  air  contained  in  the  lungs,  gives 
to  the  base  of  the  chest  a  degree  of  immobility  and  solidity,  which  affords 
a  fixed  point  for  the  muscles  inserted  there;  so  that,  in  the  effort  of  expul- 
sion, the  diaphragm,  by  its  contraction,  only  exhibits  a  power  of  resistance 
sufficient  to  sustain  the  thoracic  parietes,  but  not  an  active  force,  which  is 
to  operate,  like  the  abdominal  muscles,  directly  on  the  uterus. 

On  the  whole,  then,  the  efficient  cause  of  labor  is  inherent  in  the  Avomb 
itself.  Its  contraction  alone  is  brought  into  play  during  all  the  first  half 
of  the  labor;  but  it  is  aided  in  the  second  period  by  the  abdominal  muscles, 
which  become  more  and  more  active  as  the  labor  draws  towards  its  tormina* 


280  LABOR. 

tion.     Most  generally  the  uterine  contractions  would  be  sufficient,  but  the 
abdominal  contraction  alone  could  scarcely  ever  c(  mplete  the  delivery. 

§  2.  Determining  Causes. 

This  name  is  applied  to  everything  that  can  determine  the  action  of  the 
efficient  causes  ;  and,  as  before  stated,  this  class  consists  both  of  unnatural 
and  natural  causes.  The  second  only  claim  our  attention  here.  Ihe 
regular  and  almost  fixed  period  at  which  the  gestation  terminates  in  the 
majority  of  women,  has,  in  all  ages,  claimed  the  attention  of  physiologists. 
By  some,  the  determining  cause  of  labor  has  been  attributed  to  the  child, 
and  by  others  to  the  womb. 

1.  According  to  the  partisans  of  the  first  opinion,  the  foetus,  having 
arrived  at  a  certain  stage  of  development,  will  have  acquired  such  a  degree 
of  muscular  power  that  the  resulting  movements  of  its  limbs  will  produce 
such  blows  and  shocks  upon  the  uterine  walls,  as  will  irritate  the  organ  and 
determine  its  contraction.  2.  The  weight  of  the  infant  might  also  lead  to 
the  same  effect.  3.  Being  confined  in  the  uterine  cavity,  whose  dimensions 
have  not  augmented  in  proportion  to  those  of  the  foetus,  the  latter  will  be 
incommoded.  4.  Suffering  from  the  prolonged  accumulation  of  meconium 
in  the  intestinal  canal,  of  urine  in  the  bladder,  and  from  its  contact  with 
the  amniotic  fluids,  which  ultimately  acquire  acrid  and  irritating  properties, 
and  no  longer  finding  in  the  materials  furnished  by  the  mother  the  elements 
sary  to  its  nutrition  and  respiration,  the  infant  will  experience  a  neces- 
sity of  changing  its  residence,  of  seeking  a  medium  more  suited  to  its 
ulterior  development;  which  necessity  will  prove  an  instinctive  desire  of 
escaping  from  the  surrounding  inconveniences,  that  will  cause  it  to  give 
itself,  so  to  speak,  the  signal  of  departure.  Surely,  it  is  only  necessary  to 
present  such  reasons  as  these  in  a  summary  manner,  to  obviate  the  necessity 
of  refuting  them.  In  short,  the  foetus  is  as  foreign  to  the  determining  as  to 
the  efficient  cause  of  labor.  The  opinion  favorable  to  the  cause  residing  in 
the  uterus  rallies  around  it  a  greater  number  of  partisans,  but  all  of  these 
do  not  explain  the  mode  of  action  in  the  same  way.  Thus,  according  to 
some,  the  womb  only  possesses  the  faculty  of  distention  to  a  certain  degree, 
and,  when  carried  beyond  that  limit,  the  walls  react  and  contract;  others 
believe  that  the  term  of  nine  months  is  assigned  by  nature  for  the  fulfil- 
ment of  the  new  organization  of  the  womb;  and  having  acquired  at  that 
period  all  the  qualities  necessary  to  the  accomplishment  of  the  great  func- 
tion to  which  it  is  destined,  it  immediately  enters  into  action.  But  most 
of  the  modern  accoucheurs  consider  the  following  explanation  as  the  rnor*- 
reasonable. 

Observation  proves,  say  they,  that  the  fundus  and  body  of  the  uterus  are 
tiir  parts  firsl  distended,  for  the  purpose  of  forming  the  cavity  which  incloses 
the  product  of  conception;  and  the  cavity  of  the  neck  subsequently  par- 
ticipates in  the  dilatation,  which  begins  at  its  upper  part,  then  gradually 
descends,  so  that  the  ring  formed  of  the  external  orifice  has  alone  undergone 
but  little  alteration  at  the  approach  of  labor.  Again,  the  walls  of  the  neck 
whose  tissue  is  denser  and  more  resistant  than  that  of  the  body,  undergo 
certain  changes,  which  follow  the  same  progression  in  dilating  as  the  cavity 


CAUSES     OF     NATURAL   LABOR    AT    TERM.  281 

does  ;  their  tissue  is  saturated  with  juices  ;  they  soften  and  become  supple; 
their  fibres  untold,  as  it  were,  are  elongated  and  developed ;  and,  conse- 
quently, the  resistance  of  the  neck  to  the  escape  of  the  ovum  progressively 
diminishes  as  the  term  of  gestation  draws  near. 

According  to  this  view,  the  fibres  of  the  neck  are  considered  antagonistic 
to  those  in  the  body,  the  contraction  of  which  latter  is  therefore  reduced 
to  a  simple  tonic  action,  so  long  as  the  resistance  of  the  neck  is  superior  to 
their  power ;  but  when  this  opposition  is  diminished  by  the  progressive 
dilatation  of  the  cervix,  the  orifice  alone  remaining,  the  fibres  of  the  body 
then  begin  to  act  more  evidently,  and  their  contractions  become  more  and 
more  energetic.     (Diet,  de  Med.,  en  25  v.) 

According  to  Ant.  Petit,  the  body  only  will  dilate  prior  to  the  sixth 
month  ;  but  at  that  period  it  commences  borrowing  from  the  cervical  fibres 
the  elements  of  its  ulterior  distention,  to  which  it  can  no  longer  contribute 
itself;  and  such  contributions  will  continue  to  be  drawn  during  the  last 
three  months,  and  then,  when  all  the  fibres  held  in  reserve  by  the  neck 
shall  have  yielded,  the  distention  being  carried  to  the  utmost,  the  accouche- 
ment will  take  place.  M.  Velpeau  adopts  nearly  the  same  opinion.  On 
the  other  hand,  M.  P.  Dubois,  who  originally  advocated  the  opinions  avowed 
by  Desormeaux  in  the  first  edition  of  the  Dictionnaire,  has  since  taught, 
in  his  course  of  1837-8,  the  following  theory  proposed  by  Jones  Power, 
in  1819. 

The  uterine  tissue  at  term  may  be  justly  compared  to  that  of  the  other 
hollow  muscular  organs:  the  bladder  or  rectum,  for  example;  and,  like 
these  organs,  it  is  formed  of  two  muscular  layers,  the  external  of  which 
has  longitudinal  fibres,  and  the  internal  has  circular  ones ;  it  also  presents 
a  superior  cavity,  a  dilatable  and  contractile  reservoir,  to  which  the  struc- 
ture just  indicated  principally  belongs ;  as  also  a  closed  orifice  below, 
formed  solely  by  the  circular  fibres  arranged  as  a  sphincter  muscle.  It 
likewise  resembles  the  bladder  and  rectum  in  having  two  orders  of  nerves  — 
the  sympathetic  and  the  spinal ;  those  coming  from  the  ganglionic  system 
are  distributed  to  the  body,  while  the  others,  derived  from  the  nervous 
centres  of  animal  life,  go  to  the  neck,  which  is  a  true  sphincter  for  the 
uterus ;  the  similitude  is  further  maintained  by  the  presence  of  a  mem- 
brane lining  its  interior,  and  by  being  covered  externally,  though  at  the 
superior  part  only,  by  the  peritoneum. 

The  agreements  in  structure  are  not  the  only  ones  claiming  our  atten- 
tion;  for  the  well-marked  sympathies  existing  in  the  rectum  or  bladder, 
between  the  reservoir  and  its  sphincter,  are  found  quite  as  distinctly 
marked  between  the  body  of  the  uterus  and  its  neck;  for  as  an  irritation 
of  the  neck  of  the  bladder  or  the  sphincter  ani  is  capable  of  producing  hn 
urgent  desire  to  urinate,  or  to  go  to  stool,  so  irritations  affecting  the  cervix 
uteri  also  solicit  the  contractions  of  that  organ  ;  moreover,  it  is  well  known 
that  an  extreme  fulness  or  distention  of  the  first-named  organs  acts  me- 
chanically in  two  ways:  1.  By  irritating  their  walls  by  the  direct  contact 
of  the  contained  substances;  2.  By  dragging  or  pressing  on  the  fibres 
forming  the,  sphincter,  and  these  latter  reacting  on  those  of  the  body. 
Now,  who  does  not  recognize  in  this  resemblance,  says  Dubois,  an   easy 


282  LABOR. 

explanation  of  tlie  determining  causes  of  labor?  For,  so  1.  ng  as  the  cervix 
uteri  retains  a  certain  length,  its  most  inferior  fibres,  those  especially  sup 
plied  by  the  nerves  of  animal  life,  and  therefore  enjoying  a  high  degree  of 
sensibility,  are  not  exposed  to  any  kind  of  excitation  ;  but,  towards  the  end 
of  the  gestation,  and  in  consequence  of  the  successive  expansion  at  the 
superior  part  of  the  neck,  its  whole  length  has  disappeared  by  contributing 
to  the  gradual  development  of  the  organ  ;  a  circular  collar  alone  remaining, 
formed  of  the  horizontal  and  the  circular  fibres,  which  appertain  to 
zhe  external  orifice.  The  growth  of  the  uterus  cannot  continue  without 
producing  a  severe  tension  on  the  fibres  of  this  collar  ;  and  further,  being 
brought  immediately  into  contact  with  the  amniotic  sac,  and  consequently 
with  the  presenting  part  of  the  foetus,  they  must  necessarily  suffer,  must 
be  irritated  and  excited  by  this  constant  and  unusual  contact.  As  this 
double  cause  of  irritation  is  constantly  acting,  it  must  inevitably  happen 
with  the  fibres  belonging  to  the  body  of  the  uterus,  as  it  does  with  the 
rectal  and  vesical  walls  when  their  sphincter  is  irritated,  i.  e.  they  must 
immediately  enter  into  contraction.1 

Dr.  Tyler  Smith,  of  London,  has  lately  endeavored  to  prove,  in  accord- 
ance with  the  observations  of  Carus,  Mende,  and  Merriman,  that  the  deter- 
mining cause  of  labor  must  be  sought  for  in  the  ovary ;  that  natural  labor 
always  corresponds  with  the  tenth  menstrual  period,  and  that  the  congestion 
of  the  ovaries  produced,  by  reflex  action,  first  a  simple  irritation,  and 
ultimately  true  contractions  of  the  uterine  parietes. 

Admitting  as  proved  that  the  menstrual  ovulation  goes  on  during  preg- 
nancy, it  would  still  remain  to  be  shown  why  it  should  be  rather  at  the 
tenth  than  at  the  eighth  or  eleventh  period  that  this  influence  of  the  reflex 
action  of  the  ovary  should  be  strong  enough  to  excite  the  contractions  of 
natural  labor  in  the  uterus. 

At  one  of  the  late  sittings  of  the  Biological  Society  (September,  1855), 
M.  Brown-Sequard  suggested  a  theory  which  doubtless  is  subject  to  objec- 
tions, but  which  certainly  is  one  of  the  most  ingenious  of  all  that  have  yet 
been  proposed  in  reference  to  the  determining  cause  of  labor. 

Like  all  the  muscles,  those  especially  of  organic  life,  the  muscles  of  the 
aterus  are  very  sensitive  to  the  contact  of  venous  blood,  and  the  carbonic 

1  Mr.  Power  cites  the  following  ca?e,  communicated  by  his  brother  in  support  of  his 
opinion,  and  which  we  bring  forward  as  being  interesting  in  many  respects. 

A  lady,  the  mother  of  several  children,  supposed  herself  near  the  term  of  a  fresh 
pregnancy,  and  she  felt  two  or  three  slight  pains;  but  they  soon  passed  off  again,  and 
hree  months  more  elapsed  without  her  experiencing  any  other  pain.  Becoming 
uneasy  about  her  condition,  she  consulted  several  physicians,  who,  after  having  made 
the  usual  examination,  declared  she  was  not  pregnant.  The  author's  brother  having 
been  called  in,  participated  at  first  in  the  same  opinion;  nevertheless,  he  found  the 
ubdomen  greatly  enlarged,  and  much  inclined  forwards,  so  that  it  descended  in  front 
of  the  thighs,  almost  down  to  the  knees,  when  the  patient  was  standing.  A  distin- 
guished physician,  a  friend  of  the  lady,  who  was  present,  then  mounted  on  a  chair 
above  her,  and  by  pa^sin^r  a  towel  underneath  the  belly  raised  it  up  ;  the  vaginal 
touch  being  once  more  resorted  to,  the  child's  head  was  distinctly  felt.  A  suitable 
bandage  retained  the  *.umor  in  that  position,  and  four  or  five  days  afterwards  the  painr 
came  on,  and  the  woman  was  happily  delivered  of  a  very  large  living  infant. 


CAUSES    OF    NATURAL    LABOR    AT    TERM.  283 

aci  1  gas,  which  the  latter  contains  in  large  amount,  is  capable  of  producing 
their  contraction.  Of  the  experiments  tending  to  prove  this,  one  certainly 
seems  very  conclusive.  M.  Sequard  applied  a  ligature  to  the  trachea  of  a 
pregnant  rabbit.  Six  or  eight  minutes  after  the  commencement  of  asphyxia, 
uterine  contractions  became  manifest ;  the  ligature  was  removed,  the  con- 
tractions ceased ;  it  was  again  applied,  and  they  reappeared. 

Now,  according  to  M.  Brown-Sequard,  at  the  end  of  gestation,  the  irri- 
tability of  the  uterine  fibre  is  very  great,  and  the  development  of  the  venous 
apparatus  of  the  organ  such,  that  a  considerable  amount  of  venous  blood 
is  contained  within  its  walls.  These  two  conditions  together  constitute,  he 
thinks,  the  determining  cause  of  the  first  contraction,  since  the  excitability 
must  necessarily  be  awakened  by  the  prolonged  contact  of  carbonic  acid. 
The  effect  of  the  first  contraction  would  be  to  expel  the  blood  from  the  veins, 
and  the  contractions  would  cease  promptly  with  the  exciting  cause,  did  not  the 
pain  which  it  occasions  stimulate  the  reflex  action  of  the  spinal  marrow ; 
the  latter,  therefore,  sustains  it  for  some  moments.  But,  as  we  shall  state 
hereafter,  the  contractile  power  of  a  muscle  of  organic  life  is  rapidly  ex- 
hausted, its  fibre  relaxes,  and  repose  soon  succeeds  to  activity.  This 
relaxation  of  the  uterine  fibre  allows  the  venous  blood  to  flow  back  into 
the  uterine  sinuses,  so  that  after  a  time  the  series  of  phenomena  just  men- 
tioned recommences. 

I  have  contented  myself  with  simply  presenting  the  principal  vieAvs  that 
have  been  entertained  as  to  the  determining  cause  of  labor,  although  it 
would  be  an  easy  matter  to  start  numerous  objections  against  all  of  them, 
which  perhaps  could  not  be  set  aside.  Thus,  the  uterus  is  as  much  dis- 
tended, in  some  cases,  at  eight  months  as  it  is  in  many  others  at  nine,  with- 
out the  term  of  pregnancy  being  anticipated.  The  muscular  organization 
of  the  uterus  is  as  perfect  several  weeks  before  the  two  hundred  and  seven- 
tieth day  as  it  is  at  a  later  period.  The  sort  of  antagonism  fancied  by 
some  authors  to  exist  between  the  fundus  and  the  neck  of  the  uterus,  is  a 
pure  hypothesis  unsupported  by  evidence  ;  besides,  this  opinion,  like  that 
of  Antoine  Petit,  rests  upon  a  false  observation,  namely,  that  of  the  pro- 
gressive shortening  of  the  neck  after  the  sixth  month. 

[It  is  universally  admitted  that  delivery  is  effected  by  the  contraction  of  the 
uterus,  but  the  question  has  been  raised,  Why  does  this  contract-ion  take  place  at 
the  end  of  gestation  ?  On  this  point,  Power's  theory  seems  to  have  gained  the 
assent  of  the  majority  of  accoucheurs.  It  does  seem  to  us,  however,  that  the  ques- 
tion has  been  badly  put,  for  how  can  we  believe  that  the  muscular  fibres  of  the 
uterus  do  remain  inactive  for  nine  months,  and  enter  into  contraction  only  at  the 
termination  of  pregnancy?  We  feel  justified  in  asserting  that  the  uterus  contracts 
throughout  the  entire  period  of  gestation,  feebly  at  first,  and  rarely,  it  may  be,  but 
more  decidedly  as  the  time  progresses,  so  that  it  may  not  infrequently  be  detected 
by  palpation  of  the  abdomen  at  various  periods. 

The  contractions  are,  doubtfess,  very  slight  at  first,  though  real,  and  every  one 
knows  that  they  accomplish  the  effacement  of  the  cervix  at  the  end  of  gestation. 
Should  an  accidental  cause  increase  their  energy  prematurely,  the  result  is  either 
abortion  or  premature  delivery. 

We  would  therefore,  reverse  the  question  and  ask  why,  if  the  contractions  take 
place   throughout  the  entire  period  of  gestation,  do  they  expel   the  ryum   only  til 


284  LABOR. 

term?  The  first  reason  to  be  adduced  is,  that  the  contractions,  thi  ugh  fe/bie  aud 
insufficient  at  the  outset,  grow  stronger  as  the  development  of  the  middle  layer  of 
the  uterus  progresses,  hut  not  until  the  end  of  the  ninth  month  have  the  muscular 
fibres  acquired  sufficient  contractility  to  effect  the  expulsion  of  the  child.  In  the 
second  place  we  would  add,  that  the  contractions  which  occur  during  the  course  of 
gestation,  make  a  fruitless  effort  to  dilate  the  firm  and  resisting  tissue  of  the  uterine 
orifice. 

It  is,  therefore,  by  a  wise  precaution  of  nature  that  the  softening  of  the  cervix, 
which  takes  place  from  below  upwards,  reaches  the  internal  orifice  only  after  the 
expiration  of  the  eighth  month.  The  internal  orifice  then  yields  to  the  contractions 
which  produce  the  gradual  effacement  of  the  neck  from  above  downward.  The 
term  of  gestation  lias  now  arrived,  and  the  contractions  increase  greatly  in  strength. 
At  this  point  only,  would  I  have  recourse  to  Power's  theory,  which  seems  to  afford 
a  true  explanation  of  the  recrudescence  of  the  contractile  forces  of  the  womb  aud 
the  prompt  establishment  of  labor.] 


CHAPTER    II. 

OF   THE   PHYSIOLOGICAL    PHENOMENA    OF    LABOR. 

For  the  purpose  of  facilitating  the  study  of  the  phenomena  of  labor, 
most  writers  have  divided  them  into  several  distinct  groups,  which  they 
have  denominated  the  stages  of  labor ;  and  each  one  has  built  up  his  own 
classification,  so  that  we  may  now  enumerate  some  twenty  or  thirty.  Of  all 
these,  the  division  of  Desormeaux  appears  to  us  the  most  simple,  and  we 
shall  therefore  adopt  it.  His  first  stage  extends  from  the  beginning  of  the 
labor  to  the  complete  dilatation  of  the  cervix  uteri ;  the  second  includes  all 
the  interval  from  this  time  until  the  child  is  expelled ;  and  the  third 
embraces  the  delivery  of  the  placenta. 

Precursory  Signs.  —  The  term  of  gestation  is  most  usually  announced  by  a 
collection  of  symptoms,  to  which  the  majority  of  authors  have  applied  the 
name  of  the  "  precursory  signs  of  labor."  Thus,  during  the  last  fortnight 
of  pregnancy,  sometimes  a  little  sooner,  at  others,  only  five  or  six  days 
before  the  delivery  takes  place,  the  uterus,  which  previously  extended  up 
to  the  epigastric  region,  sensibly  sinks  lower,  and  seems  to  spread  out 
laterally ;  and  the  mechanical  obstruction  to  the  respiration  being  thus 
removed,  the  latter  becomes  more  free;  the  stomach  is  no  longer  compressed, 
and  digestion,  if  hitherto  impaired,  becomes  more  easy;  the  patient,  no 
longer  troubled  with  nausea  and  vomiting,  and  respiring  more  freely, 
becomes,  it  is  said,  ".aver,  more  cheerful,  and  disposed  to  movement.  How- 
ever true  tins  last  proposition  may  be  with  regard  to  some  women,  it  cer- 
tainly does  not  apply  to  all  ;  but,  on  the  contrary,  it  has  seemed  to  me  that 
''n  proportion  as  the  term  approaches,  their  position  becomes  more  and  more 
distressing;    and  this,  1   think,  may   be  easily  explained;    because  if  the 

respiration   1 onus  more  free,  and  the  fundus  uteri  descends,  the  inferior 

part  of  the  organ  must  also  sink  down  in  the  same  ratio.  The  head,  when 
presenting,  engages  in  the  excavation,  carrying  the  lover  portion  of  the 


PHYSIOLOGICAL     PHENOMENA    OF    LABOR.  285 

uterus  before  it;  it  sometimes  even  reaches  the  pelvic  floor,  and  consequently 
gives  rise  to  an  annoying  sensation  of  weight  about  the  fundament,  to  great 
pressure  on  the  neck  of  the  bladder  and  rectum,  strainings  at  stool,  ineffectual 
desires  to  urinate,  vesical  tenesmus,  dysury,  and  sometimes  even  to  strangury ; 
the  oedema  and  varices  of  the  inferior  extremities  and  genital  parts  then 
augment  considerably;  the  hemorrhoidal  vessels  swell  up,  and  the  tumors 
of  the  same  name,  if  they  existed  before,  become  more  voluminous  and  very 
painful ;  at  the  same  time  copious  glairy  discharges  escape  from  the  vulva. 

About  the  same  period  the  pelvic  ligaments  become  softened,  and  the 
gliding  of  the  articular  surfaces  being  rendered  easier,  the  joints  are  more 
movable,  and  consequently  walking  is  uncertain,  painful,  and  sometimes 
even  impossible.  Lastly,  to  all  these  inconveniences  and  pains,  another  is 
often  added,  which  singularly  aids  in  making  the  woman's  condition  still 
more  distressing;  it  is  this:  the  uterus,  in  the  last  periods  of  gestation, 
seems,  by  contractions,  which  are  short  and  distant  at  first,  but  soon  increas- 
ing both  in  length  and  frequency,  to  prepare,  as  it  were,  for  the  more 
violent  contractions  of  parturition.  Indeed,  she  often  experiences  the  true 
pains  from  time  to  time,  and  should  the  accoucheur  then  examine  the  abdo- 
men, he,  like  her,  will  feel  it  hardening,  and  the  uterus  manifestly  contract- 
ing. At  times,  these  contractions  are  scarcely  painful,  are  not  attended 
with  bearing  down,  and  can  only  be  detected  by  placing  the  hand  upon  the 
abdomen. 

We  know  that  the  uterine  globe  is  contracting,  from  its  greater  hardness ; 
then,  after  a  short  time,  relaxation  occurs,  and  the  walls  regain  their 
habitual  suppleness.1 

In  women  who  have  previously  had  children,  we  ascei'tain  by  the  vaginal 
touch,  that  the  membranes  bulge  out  during  contraction,  and  engage  slightly 
in  the  upper  part  of  the  cervix  uteri.  These  precursory  phenomena  are 
manifested  much  sooner  in  primiparas  than  in  others.  - 

According  to  certain  writers,  the  pains  are  felt  first,  and  with  more 
severity  than  at  any  other  time,  about  four  weeks  before  term  ;  so  that  some 
women,  who  have  been  pregnant  before,  do  not  hesitate  then  to  affirm  that 
their  labor  will  take  place  in  the  course  of  a  month.     (Burdach.) 

Further,  these  pains  are  not  wholly  useless,  for  they  tend  to  diminish  the 
thickness  of  the  neck,  and  generally  bring  on  its  dilatation  ;  thus,  I  have 
remarked  that,  when  no  cause  of  dystocia  existed,  the  labor  was  usually 
much  more  rapid  in  those  females  who  had  been  thus  tormented  by  frequent 
pains  during  the  last  fortnight  of  their  pregnancy. 

On  the  whole,  therefore,  contrary  to  the  proposition  reiterated  in  all  the 

1  These  contractions,  which  are  the  precursory  symptoms  of  labor,  I  regard  as  due 
to  the  changes  which  the  upper  part  of  the  neck  undergoes  in  t lie  latter  weeks  of  ges- 
tation. We  have  already  stated  that,  in  the  last  fortnight,  the  internal  orifice  softens 
and  yields  to  distention,  then  expands  from  above,  so  thai  the  upper  half  of  the  neck 
gradually  becomes  confounded  with  the  cavity  of  the  body;  the  lower  part  of  the 
ovum  will  evidently  engage  in  the  dilated  portion,  and  soon  come  in  contact  with  the 
parts  in  the  neighborhood  of  the  external  orifice.  This  contact  occasions  a  progres- 
sive irritation  of  the  irritable  fibres  of  the  lower  half  of  the  cervix,  which,  by  react- 
ing upon  the  body,  excites  its  control  lions,  until  finally,  the  entire  neck  bei 
the  iiritation  reaches  its  maximum,  and  labor  commences. 


286  LABOR. 

classical  works,  that  women  are  more  gay,  cheerful,  and  disposed  to  actixn^  1 
have  observed  that  they  are  in  general  more  sad,  and  are  greater  sufferers, 
than  at  other  times  ;  and  although  they  appear  to  endure  their  pains  better, 
it  is  simply  because  they  are  encouraged  by  the  hope  of  a  speedy  delivery, 
the  announcement  of  which  is  recognized  in  the  very  sufferings  they  endure. 

First  Stage.  —  The  term  of  gestation  finally  arrives,  and  the  labor  begins. 
In  primipane,  this  is  made  known  by  the  opening  of  the  neck,  which  until 
that  time  had  remained  closed  ;  and  in  other  women,  by  the  total  effacement 
of  the  rounded  collar  presented  by  the  os  tineas.  The  pains  just  mentioned 
as  occurring  in  the  last  fortnight  of  pregnancy,  suddenly  become  more 
acute  and  frequent,  and  while  they  last  the  abdomen  retracts,  and  the  uterus 
hardens,  as  may  easily  be  verified  by  examination.  If  the  fundus  was  here- 
tofore inclined  towards  the  right  or  the  left,  it  will  now  return  to  the  median 
line;  the  inequalities  of  the  foetus  can  no  longer  be  perceived  through  the 
abdominal  wall ;  the  cervix  uteri,  which  is  already  somewhat  dilated,  closes 
partially  during  the  pain,  and  its  margins  are  tense  and  resistant,  though 
growing  thinner;  the  membranes  are  distended,  press  at  first  on  the  neck, 
then  engage  in  it  as  soon  as  the  dilatation  is  sufficiently  advanced,  under 
the  form  of  a  segment  of  a  sphere,  whose  dimensions  progressively  increase 
with  the  dilatation. 

The  organs  of  generation  are  more  humid  ;  the  glairy  discharges  are 
streaked  with  blood  ;  the  pains  continue  to  increase  in  force  and  frequency, 
each  one  being  ushered  in  by  a  slight  shivering,  or  horripilation  ;  while  it 
lasts,  the  pulse  is  hard,  frequent,  and  full;  the  countenance  is  flushed,  the 
surface  and  tongue  dry,  and  the  patient  very  thirsty;  nausea  and  vomiting 
often  come  on ;  she  weeps,  desponds,  and  becomes  quite  irritable,  and,  being 
unconscious  of  the  progress  of  her  labor,  because  no  advance  is  perceived, 
she  cries  out  repeatedly,  that  she  will  never  get  over  it.  After  the  contrac- 
tion, she  is  less  agitated  ;  still,  however,  the  cessation  of  the  pain  does  not 
seem  to  be  perfect,  the  calm  is  not  yet  complete,  and  the  poor  sufferer,  still 
under  the  influence  of  the  last  pain,  dreads  incessantly  the  arrival  of  its 
successor.  During  the  interval,  the  margins  of  the  os  uteri  again  become 
nipple,  thick,  and  rounded;  the  memhranes  that  were  smooth  and  tense, 
while  the  pain  lasted,  are  now  flaccid,  and  hang  in  folds,  and  the  foetal  head, 
which  was  temporarily  removed  from  the  orifice,  seems  to  return,  and  is 
much  more  accessible  to  the  finger.  In  proportion  as  the  contractions  are 
repeated,  the  os  uteri  gradually  dilates  more  and  more,  until  at  last  it  is 
completely  opened  ;  the  cavity  of  the  uterus  and  the  vagina  thenceforth 
forming  but  a  single  uninterrupted  canal. 

Some  females  are  able  to  conceal  these  early  pains,  but  most  of  them 
find  it  impossible  to  do  so  for  any  length  of  time  ;  for,  if  conversing,  they 
will  at  once  leave  the  phrase  incomplete,  and  remain  silent  until  the  pain 
has  diminished  or  stopped  altogether;  or,  if  they  happen  to  be  walking  up 
and  down  the  chamber,  they  stop  short  and  lean  on  a  chair,  or  the  first 
article  that  comes  to  hand,  until  it  passes  over. 

The  occurrence  of  violent  shivering,  and  sometimes  of  general  tremors,  at 
the  termination  of  this  stage,  is  by  no  means  unusual,  and  that,  too,  with- 
out any  sensation  of  cold  being  perceived.     The  patient  herself  frequently 


PHYSIOLOGICAL    PHENOMENA    OF    LABOR.  287 

expresses  surprise  at  her  trembling.  It  is  doubtless  caused  by  one  of  the 
singular  impressions  produced  upon  the  nervous  system  by  the  act  of  par- 
turition. 

Second  Stage. — At  length,  under  the  influence  of  these  first  pains,  the 
duration  of  which  is  very  variable,  the  orifice  is  enlarged  until  it  forms  a 
sufficient  opening ;  and  from  that  moment  all  the  uterine  forces  are  directed 
to  the  expulsion  of  the  foreign  body  contained  within  the  organ.  Up  to  this 
time,  the  uterus  alone  was  concerned  in  dilating  the  neck,  but  it  now  seems 
to  call  in  aid  the  contraction  of  the  abdominal  muscles,  and  consequently 
both  the  pain  and  the  bearing  down  are  carried  to  a  much  higher  degree. 
The  heat  of  the  surface  is  much  more  considerable,  the  agitation  extreme, 
and  in  some  instances  there  is  even  a  marked  disorder  in  the  intellectual 
functions.  The  pains  are  stronger,  and  the  intervals  shorter  ;  nevertheless, 
the  woman  bears  them  with  more  patience,  nay,  she  even  assists  them  by 
voluntarily  contracting  all  the  muscles  of  the  trunk ;  and  each  pain  is  fol- 
lowed by  a  calm  more  perfect  than  that  in  the  first  stage.  Indeed,  when 
the  interval  is  rather  long,  some  females,  exhausted  by  the  previous  fatigue, 
sleep  profoundly,  and  thus  get  a  refreshing  repose  that  should  be  respected, 
but  which  is  soon  interrupted  by  a  new  pain.  The  inferior  segment  of  the 
membranes  gradually  engages  in  the  orifice  ;  the  successive  and  repeated 
contractions  cause  the  liquor  amnii  to  flow  towards  this  point;  the  amniotic 
pouch  becomes  tense  and  bulging  at  its  lower  part,  and,  being  entirely 
unsupported  by  the  parietes  of  the  neck,  it  gives  way,  and  the  contained 
waters  escape  with  more  or  less  rapidity  and  abundance,  according  to  cir- 
cumstances. 

Immediately,  the  foetus,  urged  on  by  the  same  contraction,  applies  itself 
to  the  os  uteri,  and  the  head,  if  that  is  the  presenting  part,  engages  like  a 
stopple  in  the  orifice,  thereby  preventing  a  further  discharge  of  the  waters. 
The  head  is  then  said  to  be  at  the  crowning.  The  rapid  discharge  of  a  con- 
siderable quantity  of  the  waters,  which  then  takes  place,  suspends  the  uterine 
contractions  for  several  moments,  and,  as  the  head  no  longer  presses  on  the 
circumference  of  the  neck,  a  small  amount  of  fluid  is  again  discharged. 
But  a  more  energetic  pain  shortly  comes  on,  by  which  the  child's  head 
advances  and  clears  the  circle  of  the  uterine  orifice,  and  just  at  this  moment 
the  patient  very  frequently  gives  a  loud  cry,  an  expression  of  the  great  pain 
caused  by  its  passage.  Next,  the  head  descends  into  the  vagina,  the  trans- 
verse folds  of  which  become  effaced,  the  canal  enlarging  and  elongating  for 
its  reception.  When  a  rupture  of  the  membranes  takes  place  before  the  os 
uteri  is  completely  dilated,  the  head  often  descends  to  the  pelvic  floor, 
though  still  retained  in  the  womb,  and  does  not  clear  the  uterine  orifice 
until  it  engages  in  the  inferior  strait;  though,  whichever  happens,  the  pains 
go  on  increasing  in  violence.  Each  one  is  announced  by  a  general  shivering ; 
the  patient  clings  to  anything  around  her,  supports  her  feet  against  the 
mattress,  throws  the  head  backwards,  takes  a  deep  inspiration,  and  violently 
contracts  all  the  muscles  of  her  body.  The  foetal  head,  being  thus  forcibly 
urged  on,  presses  against  the  floor  of  the  pelvis,  and  causes  it  to  prctrude  at 
every  pain ;  and  the  consequent  pressure  on  the  rectum  gives  rise  to  illusory 
desires  of  going  to  stool. 


288  LABOR 

After  a  greater  or  less  resistance,  the  perineum  at  last  yields,  becomes 
distended  and  bulging  in  front ;  the  vulva  partially  opens,  and  the  nymphse 
are  effaced,  the  skin  in  the  neighborhood  contributing  to  the  enlargement ; 
the  head  then  appears  in  the  dilated  vulva,  and  the  fseces  as  well  as  the  urine 
are  passed  involuntarily;  then  the  pain  again  ceases;  the  head,  just  apparent, 
now  seems  to  re-enter  the  excavation  ;  the  ovcrdistended  perineum  retracts 
from  its  own  inherent  elasticity  :  the  labia  externa  approach  each  other,  and 
the  vulva  again  closes  up;  at  each  pain,  the  latter  opens  more  and  more,  then 
retracts,  until,  at  last,  all  these  parts,  from  the  force  of  the  repeated  con- 
tractions, become  incapable  of  any  further  resistance;1  finally,  a  horrible 
pain  comes  on,  forcing  loud  cries  from  the  woman,  which  is  made  up  of  two 
others  of  unequal  violence,  for  which  nature  seems  to  have  reserved  all  her 
powers  ;  this  first  brings  the  parietal  protuberances  to  a  level  with  the  tuber- 
osities of  the  ischium,  and  then  expels  the  head  altogether  from  the  parts. 

In  some  instances,  the  delivery  of  the  body  immediately  follows  that  of 
the  head  ;  but  in  the  larger  number,  some  seconds  elapse ;  then  the  pain  is 
renewed,  the  uterus  again  contracts,  and  drives  out  the  foetal  trunk,  together 
with  the  rest  of  the  amniotic  liquid. 

The  rapid  sketch  of  these  phenomena,  just  given,  has  not  afforded  us  an 
opportunity  of  dilating  upon  any  of  them ;  nevertheless,  some  ought  to  be 
studied  more  carefully.  For  instance,  the  pain,  the  dilatation  of  the  uterin6 
orifice,  the  glairy  discharges,  and  the  rupture  of  the  membranes,  demand  a 
more  particular  attention.  We  shall,  however,  be  brief  in  the  physiological 
considerations  appertaining  to  each. 

§  1.  The  Pain,  or  Contraction. 

In  most  females,  the  pain  is  so  inseparable  from  the  contraction,  that,  in 
common  language,  the  cause  is  readily  confounded  with  the  effect,  and  the 
two  expressions  are  used,  indifferently,  to  express  the  uterine  contraction, 
its  returns,  duration,  weakness,  and  intensity.  We  must  remark,  however > 
that  although  the  intensity  of  pain  is  generally  in  relation  to  the  contrac- 
tion, yet  it  is  not  always  so,  for  the  perception  of  pain  thereby  produced 
necessarily  varies  with  the  susceptibilities  of  the  patient  herself.  Some 
experience  trifling  pains  very  acutely,  and  express  themselves  freely;  others, 
on  the  contrary,  whose  sensibility  seems  more  obtuse,  scarcely  complain  at 
all  of  the  strongest  contractions.  Again,  there  are  certain  females  who  have 
the  happy  privilege  of  being  delivered  almost  without  any  or  at  least  with 
but  very  inconsiderable  pains.  For  instance,  I  had  an  opportunity  of 
observing  a  young  primipara  at  the  Clinique,  who  was  aroused  by  the  pains 
at  four  o'clock  in  the  morning,  and  was  delivered  at  six  ;  she  suffered  so 
little  during  these  two  hours,  that  she  did  not  consider  it  necessary  to  alarm 
any  one,  and  the  midwife  was  only  summoned  when  the  pain  became  a 

1  Certain  authors  attribute  the  retreat,  of  the  head  after  each  pain  to  a  winding  of 
the  cord  around  the  child's  neck,  and  therefore  propose  various  measures  for  facili- 
tating its  delivery.  But  this  simply  results,  says  Baudelocque,  from  the  elasticity  of 
the  perineum  and  the  reaction  of  the  muscles  contained  in  its  substance,  as  also  from 
the  elasticity  of  the  cranial  bones.  Consequently,  we  have  nothing  to  do  but  to  await 
the  spontaneous  expulsion 


PHYSIOLOGICAL     PHENOMENA     OF     LABOR.  289 

little  more  severe ;  she  soon  arrived,  and  found  the  head  delivered.  This 
case  was  still  more  remarkable,  from  the  fact  of  a  partition  existing  in  the 
vagina,  which  divided  its  cavity  into  two  parts  ;  indeed  it  had  been  proposed 
to  incise  this  septum  when  the  hour  of  labor  should  arrive. 

It  is  highly  probable  that  the  dilatation  of  the  neck  goes  on  quietly  in 
such  cases,  under  the  influence  of  contractions  which  are  not  perceptible  to 
the  patient  from  being  unattended  with  pain.  The  pains  have  received 
different  names  according  to  the  period  of  their  occurrence  :  thus,  the  trifling 
ones  appertaining  to  the  precursory  phenomena  of  labor  are  named  mouches, 
from  a  comparison  with  the  sensation  caused  by  the  pricking  of  a  fly;  those 
of  the  first  stage,  in  which  the  neck  is  dilated,  are  termed  preparative;  those 
of  the  second  are  designated  as  the  expulsive ;  and  finally,  in  the  last  moments 
of  labor,  when  the  head  forcibly  distends  the  perineum  and  partially  opens 
the  vulva,  the  pains  are  so  violent  in  character  as  to  have  been  denominated 
the  conquassantes.1 

The  pains  are  felt  in  the  lower  part  of  the  abdomen ;  and  in  the  early 
stages,  generally  follow  a  line  drawn  from  the  umbilicus  to  the  second  bone 
of  the  sacrum,  but  when  the  head  presses  against  the  pelvic  floor,  they  run 
more  towards  the  coccyx.  Sometimes  they  are  felt  in  the  lumbar  and  sacral 
regions  only ;  the  women  then  call  them  the  pains  in  the  back  ;  and  the 
patient  has  good  cause  for  dreading  them,  for  they  do  not  much  advance 
the  delivery,  and  always  leave  behind  them  a  feeling  of  discomfort  and 
prostration.  These  lumbar  pains  often  come  on  early  in  the  labor,  at  othei 
times  a  little  later,  but  they  rarely  continue  till  its  close ;  sometimes  they 
coincide  with  a  great  obliquity  of  the  uterus.  According  to  Madame 
Lachapelle,  they  may  generally  be  referred  to  too  great  a  rigidity  of  the 
external  orifice,  either  because  this  experiences  a  kind  of  cramp,  or  that 
owing  to  its  unyielding  condition  it  receives  the  full  force  of  the  uterine 
efforts,  and  consequently  suffers  more  than  when  softened. 

These  lumbar  pains  doubtless  depend  on  the  sensibility  of  the  orifice,  ana 
this  can  readily  be  explained  by  the  origin  of  the  nerves  distributed  to  the 
neck,  for  the  hypogastric  and  lumbar  plexuses  furnish  them;  whilst  the 
ovarian  plexus  of  the  splanchnic  nerve  alone  sends  its  branches  to  the 
fundus  uteri.  Various  plans  have  been  tried  to  assuage  these  pains:  thus, 
venesection,  emollient  injections,  and  the  opiates,  have  often  succeeded ; 
but  there  is  one  which,  of  itself,  may  suffice  in  many  cases  to  relieve  the 
patient,  that  is,  to  raise  her  up  by  passing  a  towel  under  the  loins.  The 
pains  have  been  divided  by  writers  into  true  and  false,  according  to  wnether 
they  are  produced  by  a  regular  labor,  or  by  some  disorder  in  the  uterine 
functions;  but  as  we  shall  endeavor  to  establish  the  diagnosis  carefully 
further  on,  we  will  only  remark  now,  that  a  true  contraction  always  com- 
mences in  the  fibres  of  the  neck,  and  only  reaches  the  fundus  some  second.- 
afterwards;  and  therefore  every  contraction  beginning  at  this  latter  part  i* 
irregular  and  abnormal.  (See  chapter  on  Attentions  to  the  Woman  during 
L^bor.) 

1  I  give  these  terms  [mouches  and  conquass antra)  as  found  in  the  original,  because,  in 
our  American  practice,  they  have  no  synonyms  ;   perhaps  the  words  pricking  and  tearing 
would  express  their  sense.  —  Translator. 
19 


290  LABOR. 

The  question  now  arises,  what  is  the  cause  of  the  lahor  pain  ?  Some  sup- 
pose that  it  is  produced  by  the  tension  of  the  fibres  of  the  neck ;  others,  by 
the  pressure  on  the  nerves  distributed  to  the  internal  surface  of  the  organ, 
which  are  necessarily  compressed  by  the  foetal  walls  during  the  contrac- 
tion ;  and  lastly,  certain  accoucheurs  have  thought  that  it  was  owing  to 
the  compression  of  the  parts  contained  within  the  pelvis:  the  nervous 
plexuses,  for  example.  But  these  opinions  err  in  being  too  exclusive,  since 
all  of  these  causes  evidently  contribute  to  the  production  of  pain ;  indeed, 
there  can  be  no  doubt  that  the  dilatation  of  the  neck  is  painful  during  the 
first  stage  of  labor,  more  especially  when  the  head  is  clearing  it,  this  being, 
according  to  Madame  Boivin,  almost  the  only  source  of  suffering ;  though, 
on  the  other  hand,  when  the  child  is  so  placed  that  it  neither  rests  against 
the  uterine  orifice,  nor  yet  on  the  superior  strait,  the  contraction  is  still 
painful ;  and  the  pain  must  then  be  owing  to  the  pressure  on  the  nerves  of 
the  body  of  the  womb.  Again,  in  the  last  moments  of  parturition,  when 
the  head  is  passing  the  inferior  strait,  the  perineum,  and  vulva,  the  enormous 
distention  of  those  parts,  and  the  pressure  on  each  of  them,  must  singularly 
add  to  the  pain  produced  by  the  contraction,  as  well  as  contribute  towards 
giving  it  that  particular  character  known  under  the  name  of  the  conquas- 
sante,  or  tearing  pain. 

"Without  denying  that  these  various  conditions  may  be  the  first  cause  of 
the  pain,  M.  Beau  observes,  that  the  suffering  which  they  produce  is  not 
seated  in  the  uterus,  but  in  the  lumbo-abdominal  nerves.  He  regards  the 
pains  of  child-birth  as  being,  for  the  most  part,  a  lumbo-abdominal  neu- 
ralgia, precisely  as  though  the  case  were  one  of  pathological  disease  of  the 
uterus.  If,  says  he,  a  woman  in  labor  be  examined  with  the  object  of 
determining  the  existence  of  the  five  painful  points  which  characterize  the 
lumbo-abdominal  neuralgia,  there  will  then  be  found,  as  in  disease  of  the 
womb,  points  which  are  painful  on  pressure  in  the  lumbar,  iliac,  hypogas- 
tric, inguinal,  and  vulvar  regions.  In  some  cases,  it  is  the  lumbar  point ; 
in  others,  the  inguinal  or  iliac,  &c.  Pressure  on  the  same  points  is  much 
less  painful  during  the  interval  of  the  pains ;  in  some  cases,  indeed,  all 
tenderness  then  seems  to  disappear. 

Though  the  localization  of  the  pain  in  the  lumbo-abdominal  nerves  may 
not  explain  its  intimate  nature  and  first  point  of  departure,  it  at  least 
enables  us  to  understand  the  numerous  varieties  which  it  assumes;  just  as 
certain  grave  lesions,  and  some  extensive  displacements  of  the  organ,  are  in 
some  women  attended  with  no  pain,  whilst  with  others  a  trifling  disorder, 
or  a  slight  displacement,  gives  rise  to  extreme  suffering.  Thus,  some  women 
suffer  very  little  from  powerful  contractions,  whilst  others  complain  bitterly 
of  the  slightest  expulsive  effort.  Here,  as  in  the  pathological  case,  it  is 
impossible  to  fix  a  constant  relation  between  the  intensity  of  the  abdominal 
neuralgia  and  the  contractile  action  of  the  uterus. 

The  degree  of  pain,  as  M.  Beau  remarks,  is  owing  here,  as  in  all  other 
neuralgias,  to  the  nervous  susceptibility  of  the  female.  We  were,  there- 
fore, right  in  saying  that  the  pain  is  not  intimately  connected  with  the 
contraction. 


PHYSIOLOGICAL     PHENOMENA    OF    LABOR.  291 

I  The  pai.3  which  accompanies  the  uterine  contractions  is  not  a  unique  fact  in  the 
organism,  inasmuch  as  all  rather  severe  involuntary  contractions,  in  whatever  organ 
they  may  take  place,  are  attended  with  pain.  I  would  mention  in  illustration, 
cramps  in  the  muscles  of  the  animal  life,  colic  pains  in  the  bowela,  spasmodic 
contractions  of  the  bladder,  and  palpitations  of  the  heart.  Under  ordinary  circum- 
stances, it  is  true  that  the  muscles  of  the  limbs,  of  the  intestinal  canal,  of  the 
bladder,  and  of  the  heart,  are  constantly  contracting  without  pain,  but  the  moment 
they  become  affected  with  severe  involuntary  contraction,  pain  is  experienced. 
This  would  seem  to  be  a  law  of  pathological  physiology  which  is  as  applicable  to 
the  uterus  as  to  any  of  the  other  organs.  We  believe,  therefore,  that  the  pains  of 
labor  have  their  seat  in  the  uterine  Avails  precisely  as  colic  pains  are  situated  in  the 
walls  of  the  intestines.  The  painlessness  of  the  contractions  which  take  place 
during  pregnancy,  is  explained  by  their  feebleness,  and  are  comparable  to  the 
peristaltic  motions  of  the  bowels  of  which  we  are  unconscious.] 

Still  another  question  has  been  agitated  by  physiologists,  that  is,  why  is 
the  contraction  intermittent?  and  here  far-fetched  reasons  have  been 
adduced  to  explain  a  very  simple  phenomenon  ;  just  as  if  any  single  muscle 
of  the  economy  could  contract  permanently ;  as  if  it  were  not  the  nature  of 
all  muscular  contraction  to  be  interrupted  by  the  fatigue  of  a  too  prolonged 
exercise,  and  as  if  it  must  not  have  an  interval  of  repose,  in  order  to  pre- 
serve its  activity.  Besides,  if  the  uterine  contractions  are  dependent  upon 
the  nerves  of  organic  life,  why  should  they  not  be  subject  to  the  periodicity 
which  marks  the  muscular  apparatus  supplied  by  branches  from  the  great 
sympathetic?  We  are  doubtless  ignorant  of  the  cause  of  the  rhythmic 
intermissions  in  the  contraction  of  the  heart,  as  well  as  of  the  stomach  and 
intestines ;  what  cause  is  there,  therefore,  for  greater  astonishment  at  the 
interm ittence  of  the  uterine  action,  subject  as  it  is  to  the  same  nervous 
influence  ? 

It  is  certainly  very  curious  to  study  the  influence  of  the  contraction  over 
the  mother's  circulation,  which  exhibits,  according  to  Holl,  the  following 
peculiarities  during  a  pain.  In  general,  the  pulse  is  accelerated  as  soon  as 
the  contraction  begins,  increasing  in  frequency  as  it  goes  on,  then  diminish- 
ing, and  gradually  resuming  the  normal  type.  Now  there  exists  so  intimate 
a  relation  between  these  two  phenomena,  that,  where  the  pulse  is  gradual 
in  its  acceleration,  where  it  arrives  little  by  little  to  the  maximum  of  its 
rapidity,  is  there  sustained  for  a  certain  length  of  time,  and  finally  recedes 
by  degrees,  the  pain  also  follows  an  equally  regular  course ;  it  gradually 
attains  its  maximum  intensity,  remains  a  while  stationary,  and  then 
decreases  with  the  same  regularity;  but,  on  the  contrary,  if  tho  pulse 
accelerates  by  jerks,  the  contraction  will  be  short  and  precipitate,  and 
therefore  without  effect.  Holl  ascertained  this  regularity  in  the  phenomeua, 
by  counting  the  pulsations  by  quarters  of  a  minute  during  the  whole  time 
a  pain  lasted.  For  instance,  he  noted  the  following  variations  in  a  con 
taction  which  lasted  two  minutes: 

First  minute, 
Second  minute, 


First  and  second  quarters,  each, 

.     18 

pul 

~;itioii9. 

Third  quarter, 

.     20 

" 

Last  quarter, 

22 

" 

First  and  second  quarters,    . 

.     24 

" 

Third  quarter, 

22 

(1 

Last  quarter, 

.     18 

a 

292  LABOR. 

Ill  proportion  as  the  labor  advances,  the  pulse  accelerates  the  more  ;  so  thai, 
n  little  while  before  delivery,  it  has  the  same  frequency  in  the  intervals  as 
it  had  at  first  during  the  strongest  contractions.  We  have  already  pointed 
out  the  modifications  in  the  bellows  murmur,  noticed  by  the  same  obsti  ver 
during  the  pain,  and  shall  not  repeat  them  now,  merely  remarking,  how- 
ever, that  they  are  sufficiently  well  marked  to  indicate  the  uterine  contrac- 
tion, even  when  the  woman  herself  may  be  desirous  of  concealing  it. 

§  2.  Dilatation  of  the  Os  Uteri. 

The  foetus  evidently  has  no  part  in  the  dilatation  of  the  os  uteri  until 
the  bag  of  waters  is  ruptured.  It  is  not  until  after  this  event  takes  place, 
that  the  vertex,  by  engaging  like  a  wedge  in  the  uterine  neck,  can  hasten 
the  dilatation  mechanically;  and  it  is  equally  evident  that,  in  any  other 
than  a  vertex  position,  the  presenting  part  being  more  voluminous  and 
irregular  than  the  head,  cannot  perform  the  same  office,  and  therefore, 
costeris  paribus,  the  orifice  will  open  more  slowly.  Hence,  it  is  not  the  foetus, 
at  least  during  the  fir^t  part  of  the  labor,  which  is  the  efficient  cause,  but 
here  also  the  phenomenon  is  referable  to  the  contraction  of  the  uterine  fibres. 

Now,  in  order  to  understand  how  this  occurs,  we  must  remember,  says 
Desormeaux,  that  the  walls  of  the  womb  are  applied  to  an  ovoid  body  ;  that 
the  longitudinal  fibres  are  the  most  numerous,  and  that  the  circular  fibres 
of  the  cervix,  although  capable  of  stoutly  resisting  their  power,  yet  are 
gradually  constrained  to  yield  to  the  action  of  the  longitudinal  ones.  If  we 
now  imagine  these  latter  fibres  to  enter  into  contraction,  we  shall  readily 
comprehend  that,  being  unable  to  diminish  the  distended  uterine  cavity,  all 
their  power  must  be  exerted  in  drawing  upon  those  points  of  the  circle  which 
form  the  orifice,  where  each  one  is  inserted,  and  thus  remove  them  from  the 
centre  of  the  opening.  Wherefore,  every  portion  of  the  orifice  being  equally 
operated  upon,  it  will  present  a  circular  form ;  but  if  the  foetus  is  placed 
transversely,  and  the  womb  dilated  in  that  direction,  the  fibres  being  re- 
tracted more  in  the  same  diameter,  the  orifice  will  be  elliptical. 

The  rapidity  of  the  dilatation  bears  a  direct  ratio  to  the  force  and  fre- 
quency of  the  contractions.  In  general,  it  is  very  slow  in  the  commencement 
of  labor,  but  much  more  rapid  towards  its  close :  for  instance,  if  the  opening 
dilated  to  the  extent  of  one  inch  in  four  hours,  it  would  only  require  two,  or 
at  most  three  hours  for  its  complete  enlargement ;  this  progresses  more 
slowly,  however,  in  primiparse  than  in  other  women.  Again,  the  softness, 
or  the  rigidity  and  tension,  of  the  neck  during  the  intervals  of  pain,  has  a 
great  influence  over  the  rapidity  of  its  dilatation  ;  and  the  same  may  be  said 
of  the  obliquity  of  the  orifice;  for  when  this  latter  is  carried  in  front 
towards  the  pubis,  or,  what  is  still  more  frequent,  is  strongly  directed  back- 
wards towards  the  sacrum  —  in  either  case,  the  neck  is  no  longer  placed  in 
the  axis  of  the  contractions,  and  the  head  is  forcibly  pressed  towards  some 
part  of  the  uterine  wall,  against  which  all  the  expulsive  force  is  lost. 

It  is  likewise  important  to  bear  in  mind,  thai  the  posterior  obliquity  of 
the  neck  may  be  owing  to  an  anterior  inclination  of  the  womb,  and  may 
also  exist  without  the  latter  being  at  all  changed  from  its  normal  position  ; 
this  results  from  the  head  having  been  engaged  a  long  time  in  the  excava- 


PHYSIOLOGICAL     PHENOMENA    OF     LABOR.  293 

tion,  and  having  pushed  the  anterior  inferior  uterine  wall  before  it;  the  os 
atari  being  at  the  same  time  carried  upwards  and  backwards. 

[When  the  orifice  is  directed  very  far  backward,  it  is  sometimes  difficult  to  reach, 
and  some  practitioners  make  the  mistake  of  supposing  that  the  dilatation  is  com- 
pleted even  -when  the  head  is  entirely  covered  by  the  anterior  segment  of  the  womb.' 

This  eri'or  is  most  liable  to  occur  in  first  labors,  for  then  the  edges  of  the 
orifice  are  extremely  thin,  and  when  the  head  distends  and  presses  down  the  lower 
segment  of  the  uterus  without  interposition  of  the  amniotic  fluid,  the  sutures  and 
fontanelles  may  be  felt  so  easily  as  to  lead  to  the  supposition  that  the  head  is 
uncovered.  A  mistake  of  this  nature  may  have  serious  consequences.  I  have 
myself  seen  attempts  made  to  apply  the  forceps  under  these  circumstances.  To 
avoid  misconception,  the  hips  of  the  patient  should  be  raised,  the  fingers  passed 
very  far  back  and  moved  over  the  contour  of  the  head.  If  the  orifice  is  really 
dilated,  the  finger  will  penetrate  very  deeply  and  pass  alongside  of  the  head  with- 
out meeting  any  obstacle.  If,  however,  dilatation  has  not  been  accomplished,  the 
linger  is  soon  arrested  by  the  neck  of  the  vaginal  sac  —  especially  in  front.] 

The  orifice,  which  is  generally  very  thin  in  primiparae  at  the  beginning  of 
labor,  becomes  thicker  towards  the  last  half  of  the  first  stage ;  then  it  gets 
thinner,  and  finally  forms  a  thick,  rounded  collar,  which  the  head  pushes 
before  it  as  far  as  the  inferior  strait. 

The  reason  of  these  various  changes,  says  M.  Guillemot,  is  very  simple ; 
for  the  pressure  upon  the  neck  acts  more  forcibly  on  the  periphery  of  the 
orifice  than  on  any  other  part,  and  the  consequent  thinning  will  disappear 
as  soon  as  the  uterine  circle  yields,  and  is  carried  back  towards  the  parts 
that  have  not  suffered  an  equal  pressure,  but  have  maintained  their  original 
thickness;  though  soon  af^er,  in  consequence  of  fresh  pains,  the  tension  on 
this  new  circle  will  destroy  its  bulk  and  reduce  it  to  the  condition  stated. 
Finally,  a  period  arrives  when  the  neck  maintains  its  thickness,  notwith- 
standing the  dilatation  it  undergoes,  because  the  uterine  fibres,  being  exces- 
sively shortened,  give  more  density  to  this  part.  I  will  add  that  the  thick- 
ness of  the  anterior  lip  is  often  greatly  augmented,  when  the  engagement  is 
far  advanced,  by  oedema  of  the  part,  due  to  its  compression  between  the 
head  and  the  symphysis  pubis ;  and  further,  that  it  is  not  at  all  uncommon 
to  find  the  posterior  lip  quite  thin,  whilst  the  anterior  one  still  remains  con- 
siderably thickened. 

§  3.  Of  the  Glairy  Discharges. 

We  have  already  learned  that  an  abundant  secretion  takes  place  in  the 
vagina  during  the  latter  periods  of  gestation  ;  but  when  the  labor  sets  in, 
this  secretion  augments  very  considerably,  and  discharges  of  viscid  mucus, 
resembling  the  white  of  an  egg,  designated  as  the  glairy  discharges,  flow 
from  the  womb  and  vagina.  In  some  women  they  become  sanguinolent  at 
the  approach  of  the  travail;  but  in  others  they  are  only  so  during  labor. 
When  blood  is  thus  mixed  with  the  other  fluids,  it  is  said  to  be  an  evidence 
that  the  dilatation  of  the  orifice  is  advanced  ;  this,  however,  is  not  always 
true,  since,  in  some  instances,  several  days  elapse  before  the  commencement 
of  parturition.    In  some  cases, indeed,  they  are  wholly  absent,  and  the  labor 

1  Sometimes  the  orifice  is  so  thin  that  the  finger  slips  over  it  without  perceiving  it. 


294  LABOR. 

is  then  said  to  be  a  dry  one;  the  genital  parts  experiencing  a  degree  of  heat 
and  dryness  almost  akin  to  inflammation. 

With  regard  to  their  origin,  these  discharges  are  not,  as  Ant.  Petit  and 
Baudelocque  supposed,  the  product  of  a  transudation  of  the  amniotic  waters 
through  the  pores  in  the  membranes  ;  but  they  simply  result  from  the  more 
abundant  secretion  of  the  mucous  cryptse  in  the  neck  and  vagina ;  a  secre- 
tion which  is  augmented  by  the  greater  irritation  in  those  parts,  caused  by 
the  labor.  As  to  the  blood  that  colors  them,  whether  before  or  during  tho 
labor,  it  may  come  either  from  some  slight  laceration  in  the  borders  of  the 
orifice,  from  a  rupture  of  some  of  the  minute  vessels  which  run  from  the 
internal  uterine  surface  to  be  distributed  upon  the  membranes,  or  from  the 
detachment  of  a  small  portion  of  the  placenta ;  or,  according  to  Desor- 
meaux,  it  may  escape  from  the  extremities  of  the  capillaries  without  any 
discoverable  rupture. 

These  mucosities,  commencing  as  we  have  before  seen  in  the  latter  weeKs 
of  gestation,  serve  to  lubricate  the  genital  passages,  and  while  relieving  tho 
vaginal  walls  and  the  parietes  of  the  neck  from  their  engorgement,  the;* 
have  the  further  advantage  of  moistening  those  parts,  of  softening  the 
perineum  and  the  vulvar  orifice,  and  thus  rendering  the  extreme  distention 
which  all  of  them  must  shortly  undergo  more  easy.  Their  abundance  is 
always  to  be  considered  a  good  sign,  presaging  a  prompt  dilatation  and  an 
easy  expulsion. 

§  4.  Of  the  Bag  of  Waters. 

As  the  neck  progressively  dilates,  the  foetal  membranes  present  and 
become  engaged  therein,  forming  a  tumor  of  variable  size  in  the  vagina, 
which  is  tense  at  the  moment  of  contraction ;  and  this  is  what  is  understood 
by  the  formation  of  the  bag  of  waters.  The  sac  varies  in  its  shape  with  the 
figure  represented  by  the  uterine  orifice ;  it  is  generally  rounded  and  hemi- 
spherical, though  ovoid  when  the  cervix  uteri  dilates  more  in  one  diameter 
than  another ;  when  the  membranes  are  formed  of  a  loose,  uncontracted 
tissue,  and  especially  when  they  contain  but  a  small  quantity  of  liquid, 
they  may  form  an  elongated  tumor  in  the  vagina,  without  being  a  necessary 
sign  of  a  presentation  of  either  the  hand  or  the  foot,  as  some  have  incorrectly 
Bupposed. 

We  must  acknowledge,  however,  that  the  bag  of  waters  is  usually  less 
voluminous  in  vertex  presentations  than  in  others ;  and,  consequently,  that 
a  very  great  protrusion  of  it  nearly  always  announces  an  unfavorable  posi- 
tion. This  occasioned  the  remark  of  Madame  Lachapelle :  "  I  do  not  fear 
the  flat  sacs."  As  soon  as  the  pain  ceases  the  tumor  disappears,  the  fluid 
that  formed  it  re-enters  the  uterine  cavity,  and  the  flaccid,  relaxed  mem- 
branes hang  in  folds. 

[The  bag  of  waters,  says  Prof.  Depaul,  sometimes  assumes  another  form  which 
I  have  called  the  double  bag,  and  is  indicative  of  a  twin  pregnancy. 

I  first  met  with  it  whilst  Interne  at  the  Maternity  Hospital  in  1839,  and  waa 
much  puzzled  by  it,  inasmuch  as  I  had  never  met  with  any  account  of  it  and 
became  aware  of  its  significance  only  after  the  birth  of  the  twins. 

Some  years   after  I   met  with   the  same  thing  at  the   lying-in  hospital  of  the 


PHYSIOLOGICAL     PHENOMENA     OF     LABOR.  295 

Faculty,  and  remembering  my  former  observation  at  the  Maternity,  did  noi  hesitate 
to  assert  that  there  were  two  children,  —  which,  in  fact,  were  soon  born.  These 
are,  however,  the  only  cases  which  I  have  met  with,  nor  ought  their  rarity  to  be  a 
matter  of  surprise  when  we  consider  all  the  conditions  required  in  order  that  two 
ovums,  which  are  liable  to  assume  such  various  positions  in  the  cavity  of  the  uterus 
should  be  equally  forced  upon  the  mouth  of  the  womb  by  the  contractions.  Still 
it  is  well  to  record  the  fact  in  order  that  it  may  be  made  available  upon  occasion.] 

The  formation  of  the  sac  is  easily  understood.  Fl°- 74- 

The  uterine  cavity  is  gradually  diminished,  and 
the  amniotic  liquid,  pressed  on  all  sides,  natu- 
rally flows  towards  the  point  that  offers  the 
least  resistance,  and  such  point  is  evidently  the 
opening  in  the  neck  where  no  walls  are  found. 
The  reason  why  so  much  difficulty  existed  in 
comprehending  how  the  membranes  could  pro- 
ject into  the  vagina  under  the  influence  of 
this  pressure  of  the  liquid,  was  because  the 
amniotic  cavity  was  supposed  to  be  distended 
to  the  utmost  by  the  waters,  and  consequently 
that  there  must  either  exist  a  very  great 
extensibility  of  the  membranes,  or  else  a  trans-       The  form  of  the  bas  of  wate" 

,.  ft         n     •  ^      i  ii  n         n     i  when  the  os  uteri  is  fully  dilated. 

udation  of   the  fluid  through  the  walls  of  the 

ovum ;  but  both  hypotheses  are  false.  For  it  is  only  necessary  to  press 
upon  the  abdomen  of  a  pregnant  woman  to  become  satisfied  that  in  most 
females  a  very  slight  pressure  will  be  sufficient  to  flatten  the  ovum,  whether 
in  its  vertical,  transverse,  or  antero-posterior  diameters.  This  is  what  takes 
place  in  labor,  excepting  that  the  ovum  can  only  elongate  below,  on  account 
of  the  uterine  pressure  upon  all  other  parts,  and  thus  produces  the  amniotic 
tumor. 

When  the  dilatation  is  completed  and  the  contraction  energetic,  the 
inferior  part  of  the  membranes,  being  no  longer  supported,  soon  yields  to 
the  impulse,  and  becomes  ruptured,  thereby  permitting  a  variable  quantity  of 
liquid  to  escape.  Where  the  pouch  is  voluminous,  and  gives  way  just  at 
the  moment  of  a  strong  pain,  the  rupture  takes  place  with  such  a  loud  noise, 
that  women  in  their  first  labor  are  often  much  alarmed,  and  then  also  the 
waters  gush  out  in  large  quantity.  But  where  the  pouch  is  flat,  and  only  a 
small  quantity  of  fluid  is  interposed  between  the  head  and  the  membranes, 
the  latter  are  lacerated  without  any  noise,  and  but  a  little  liquid  oozes  out 
after  their  rupture ;  because,  the  head  by  engaging  at  once  in  the  os  uteri 
obliterates  it  completely  and  blocks  up  the  waters. 

[When  the  membranes  are  ruptured,  the  following  peculiarities  mav  be  observed 
in  the  discharge  of  the  amniotic  fluid.  At  the  beginning  of  each  contraction,  it  is 
forced  toward  the  lower  segment  of  the  uterus  and  a  small  quantity  is  discharged 
from  the  vulva.  At  the  height  of  the  contraction  the  flow  is  arrested,  because  the 
direct  application  of  the  head  against  the  orifice  stops  it  completely.  Finally,  when 
the  contraction  subsides,  the  head  will  close  the  orifice  imperfectly  and  allow  afresh 
quantity  to  escape  externally.] 

In  the  vast  majority  of  cases,  the  membranes  are  lacerated  on  that  pc  rtiou 


296  LABOR. 

of  the  bag  corresponding  to  the  uterine  orifice.  But  sometimes  the  rupture 
occurs  much  higher  up;  and  this  fact,  which  is  almost  inexplicable  in  the 
present  state  of  our  knowledge,  should  nevertheless  be  known,  because  it 
accounts  for  the  circumstance  of  the  inferior  segment  of  the  ovum  being 
then  found  intact  after  the  discharge  of  a  certain  quantity  of  water,  and  of 
our  having  to  puncture  the  membranes  subsequently  in  this  part.  Some- 
times thev  are  ruptured  in  the  beginning  of  the  labor,  which  is  thereby  usually 
rendered  longer  and  more  difficult  for  the  mother,  as  also  more  dangerous 
for  the  child,  especially  when  a  considerable  quantity  of  water  escapes  at 
the  same  time.  Besides  these  varieties,  I  have  several  times  noticed  a 
remarkable  peculiarity  that  seems  to  have  escaped  the  attention  of  practi- 
tioners generally  ;  I  allude  to  the  occurrence  of  a  rupture  before  any  con- 
traction of  the  uterus  whatever.  This  constitutes  in  a  fe-.v  females  the  first- 
phenomenon  of  the  labor ;  but  the  pains  do  not  come  on  for  some  time 
afterwards,  occasionally  not  for  several  days.  Now,  this  premature  lacera- 
tion has  seemed  to  me  to  be  coincident  with  a  presentation  of  the  vertex 
that  is  deeply  engaged  in  the  excavation ;  for  although  the  patient  felt  no 
previous  pain,  and  even  in  certain  cases  was  sleeping  profoundly  when  the 
waters  escaped,  it  is  highly  probable  that  the  uterus  had  already  been  con- 
tracting for  some  time,  and  the  occurrence  may  be  referred  to  those  non- 
painful  contractions  hitherto  described ;  unless,  perhaps,  it  may  possibly 
depend  on  an  excessive  distention  of  the  amniotic  pouch. 

Sometimes  the  membranes  are  very  hard,  thick,  and  resistant,  the  rupture 
only  taking  place  at  an  advanced  stage  of  the  labor,  when  the  head  clears 
the  vulva,  for  instance ;  or  it  may  occur  in  a  circular  manner,  and  the  head 
escape  covered  by  a  kind  of  hood.  The  child  is  then  said  to  be  born  with 
a  caul,  and  the  vulgar,  from  that  circumstance,  prophesy  a  happy  future. 

The  infant  may  also  be  born  hooded,  when  a  rupture  of  the  membranes 
first  occurs  at  an  elevated  point,  one  not  corresponding  at  all  with  the 
uterine  neck ;  and  should  the  head  then  push  before  it  a  portion  of  the 
amniotic  pouch,  serious  accidents  might  result  in  consequence :  for  instance, 
this  late  rupture  might  delay  the  labor,  or  the  tension  experienced  by  the 
membranes,  extending  to  the  placenta,  may  cause  its  premature  detachment, 
especially  when  it  is  inserted  on  the  sides  of  the  organ,  and  thus  produce  a 
uterine  hemorrhage. 

In  ordinary  cases,  the  rupture  takes  place  at  the  commencement  of  the 
second  stage. 

The  subjoined  is  a  statistical  summary  made  by  Churchill,  at  the  Western 
Lying-in  Hospital,  during  the  years  1841  and  1842,  which  will  enable  the 
reader  to  judge  of  the  varieties  that  may  be  met  with. 

The  period  elapsing  between  the  commencement  of  the  labor  and  the 
rupture  of  the  membranes  has  been  noted  in  984  cases.     Thus: 


[n  167 

females, 

this 

time 

was 

o 

b 

ours. 

"  335 

<< 

" 

from  2  to    6 

" 

"   165 

<< 

" 

«     6  "  10 

" 

"  113 

u 

i< 

«  10  "  14 

" 

«     71 

it 

a 

»  14  "  18 

" 

«•     88 
'•     46 

n 

"  18  "  22 
"22  "  26 

" 

PHYSIOLOGICAL    PHENOMENA    OF    LABOR.  297 


In    23  female3  this  time  was  from 

26 

1  30  hours. 

«       g 

30 

«  38      " 

.<       9 

38 

'  40      " 

4         "                   •'             about 

50      " 

2        "                  "                 " 

60      " 

.«        4 

70      " 

„       3 

80      " 

"       1  female               " 

105      " 

984 

The  same  observer  noted  the  time  from  the  rupture  of  the  membranes 
ontil  the  child's  birth  in  812  cases. 


In  396 

women, 

this  time  was 

1  h 

our 

"  142 

(i 

" 

2  hours 

»  120 

<< 

" 

4 

" 

"     50 

(< 

" 

6 

si 

"     34 

" 

•' 

8 

it 

«     17 

" 

" 

10 

" 

«     26 

» 

" 

15 

" 

"     11 

" 

" 

20 

« 

"       3 

»« 

" 

28 

" 

»       4 

(< 

" 

35 

<< 

1 

woman 

" 

40 

" 

"       1 

<  < 

<< 

50 

" 

"       1 

» 

" 

150 

" 

812 


§  5.  Of  the  Duration  of  Labor. 

The  duration  of  labor  is  exceedingly  variable,  even  when  no  obstacle 
opposes  its  natural  course.  Some  women  are  delivered  in  an  hour  or  two, 
whilst  others  are  not  for  several  days ;  and  between  these  two  extremes, 
there  is  every  intermediate  grade. 

The  published  statistics  are  hardly  reliable,  for  most  of  them  have  been 
collected  in  hospitals ;  and  it  is  a  fact,  that  the  majority  of  women,  dread- 
ing to  be  taken  into  the  apartment  devoted  to  the  patients  in  labor,  conceal 
their  first  pains,  and  give  up  only  when  they  can  restrain  themselves  no 
longer.  Therefore,  when  interrogated  after  delivery,  their  statements  are 
not  found  to  coincide  with  their  record,  and  make  their  labor  appear  much 
longer  than  the  latter  would  indicate.  This  correction  seems  to  me  of 
importance,  for  most  physicians  of  limited  experience,  having  learned  that 
the  duration  of  labor  is  from  five  to  six  hours,  are  apt  to  become  alarmed 
unnecessarily  when  they  find  it  continuing  even  longer  than  from  ten  to 
twelve  hours. 

In  general,  it  is  longer  in  primiparse  than  in  others ;  and  this  difference 
is  chiefly  owing  to  the  resistance  of  the  perineal  muscles,  which  is  much 
greater  in  the  former,  though  it  is  also  influenced  by  the  dilatation  of  the 
neck,  which  is  effected  in  them  very  slowly. 

The  whole  length  of  their  labor  is  usually  from  ten  to  twelve  hours,  but 
it  should  be  known  that,  in  at  least  one  case  in  five,  it  may  not  terminate 
under  fifteen,  eighteen,  or  even  twenty  hours,  and  this  without  any  injury 


298  LABOR. 

whatever  resulting  either  to  the  mother  or  the  child.  "Women  who  have* 
had  children  are  delivered  much  sooner,  only  suffering,  in  ordinary  cases, 
about  six  or  eight  hours.  According  to  Alph.  Leroy  and  Velpeau,  the 
pains  are  apt  to  observe  periods  of  six  hours :  that  is,  the  labor  lasts  either 
six,  twelve,  eighteen,  twenty-four,  or  thirty  hours.  I  think,  if  their  obser- 
vation be  correct,  it  will  be  found  subject  to  very  numerous  exceptions. 

But,  supposing  the  labor  has  really  commenced,  can  we  predict  the  hour 
of  its  termination  with  any  degree  of  certainty?  This  question,  which  is 
nearly  always  addressed  to  the  accoucheur,  is  oftentimes  a  very  difficult  one 
to  answer,  for  habit  alone  can  enable  us  to  judge  by  the  dilatation,  or  the 
suppleness  of  the  neck ;  by  its  tension,  its  hardness,  and  resistance ;  by  the 
frequency  and  intensity  of  the  pains ;  by  the  time  it  has  already  existed, 
and  by  the  greater  or  less  resistance  of  the  vulva  and  perineum,  of  the 
probable  length  of  the  labor. 

It  must  also  be  remembered,  in  regard  to  the  duration,  that  the  first  stage 
of  labor  is  to  the  second,  as  two,  or  even  three,  to  one ;  and,  further,  this 
difference  is  still  more  marked  in  women  who  have  had  children,  than  in 
primiparae;  and  that  the  first  half  of  the  dilatation  of  the  neck  is  much 
slower  than  the  second.  But  how  many  exceptions  are  there  to  this  law! 
For  instance,  the  dilatation  is  sometimes  regular,  and  sufficiently  rapid, 
everything  seeming  to  promise  an  easy  and  prompt  termination  ;  yet  all  at 
once  the  pains  become  feeble  and  languishing,  and  our  art  is  often  obliged 
to  interpose  in  aid  of  the  uterine  contractions ;  while,  on  the  contrary,  it 
not  unfrequently  happens  that  the  neck  is  expanded  with  an  excessive 
degree  of  slowness,  after  which,  a  few  moments  will  suffice  to  effect  the 
delivery. 

The  form  of  the  vagina,  according  to  Wigand,  should  also  be  taken  into 
consideration,  in  making  a  prognosis  as  to  the  probable  duration  of  the 
labor:  thus,  if  this  canal  is  large  throughout,  the  whole  time  will  be  short; 
and,  on  the  other  hand,  the  dilatation  of  the  cervix,  and  the  expulsion  of 
the  child  will  be  very  slow,  should  the  vaginal  cavity  be  regularly  con- 
tracted throughout  its  extent;  again,  if  the  vulvo-uterine  canal  is  large  and 
spacious  superiorly,  but  contracted  and  unyielding  near  the  external  orifice, 
the  first  part  of  the  labor  will  be  prompt,  but  the  last  slow  and  difficult ; 
and,  finally  (though  more  rarely),  if  its  upper  extremity  is  very  narrow,  the 
inferior  being  at  the  same  time  largely  dilated,  we  may  conclude  that  the 
parturition  will  progress  slowly  at  first,  but  will  then  terminate  speedily. 

It  is  a  very  singular  fact,  that  an  hereditary  influence  is  sometimes  mani- 
fested in  the  process,  it  being  not  at  all  uncommon  to  find  the  same  pecu 
uarities   transmitted    through   three  or  four   successive   generations ;    the 
mother,  the  daughter,  and  the  granddaughters  being  remarkable  either 
for  the  slowness  or  rapidity  of  their  labors. 

In  general,  it  is  impossible  to  predict  with  any  degree  of  certainty  the 
hour  of  its  termination  ;  yet  most  people  seem  to  imagine  that  the  physician 
is  bound  to  give  the  most  particular  information  on  this  point.  He  must, 
however,  always  be  very  guarded  in  his  replies,  for  should  the  labor  over- 
run the  fixed  time  by  some  hours,  it  would  give  rise  to  the  most  anxious 
solicitude,  and  it  is  therefore  prudent  not  to  be  too  precise.     When   such 


PHYSIOLOGICAL     PHENOMENA    OF     LABOR.  299 

questions  are  addressed  to  me,  I  am  in  the  habit  of  saying,  that,  if  the 
contractions  are  regular,  and  no  accident  occurs,  if,  in  a  word,  all  things 
go  on  right,  the  delivery  will  take  place  at  the  hour  I  name. 

In  fact,  it  is  absolutely  impossible  to  foresee  all  that  may  happen ;  be 
cause,  in  certain  cases,  the  dilatation  of  the  os  uteri,  which,  perhaps,  only 
amounted  to  one  inch,  after  five  or  six  hours  of  labor,  is  suddenly  com- 
pleted ;  and,  at  other  times,  this  process  being  very  little  advanced,  the 
margin  of  the  orifice  is  lacerated  under  the  influence  of  a  strong  pain,  and 
the  delivery  effected,  perhaps,  just  as  the  physician  has  announced  that  the 
labor  will  still  last  for  several  hours.  In  examining  a  young  woman,  preg- 
nant for  the  first  time,  I  found  the  orifice  dilated  to  the  size  of  a  quarter 
of  a  dollar,  and,  supposing  that  the  labor  would  last  for  some  time,  I  with- 
drew, but  scarcely  had  I  reached  the  foot  of  the  staircase,  when  a  messenger 
came  running  after  me  in  great  haste;  I  immediately  returned,  and  found 
the  head  on  the  point  of  clearing  the  vulva,  which  was  already  considerably 
opened.  After  the  labor  was  over,  I  ascertained  that  the  whole  left  side' 
of  the  vaginal  portion  of  the  neck  had  been  lacerated. 

A  young  primiparous  female  experienced  the  first  pains  at  four  o'clock  in 
the  morning.  Throughout  the  day  the  contractions  were  very  feeble,  with 
intervals  varying  from  a  quarter  of  an  hour  to  an  hour.  The  dilatation 
was  so  slow,  that  at  four  o'clock  in  the  afternoon  the  orifice  had  barely 
attained  the  size  of  a  dime.  After  five  o'clock,  the  pains  were  rather 
stronger  and  quicker ;  at  nine  P.  M.,  the  neck  was  very  thin,  and  presented 
an  opening  of  three-quarters  of  an  inch  in  diameter.  Being  obliged  to 
leave  the  patient  for  an  hour,  I  thought  I  might  do  so  with  safety,  but  imme- 
diately after  my  departure  the  contractions  became  powerful,  and  at  a 
quarter  before  ten,  she  gave  birth  to  a  very  small  child,  which  barely 
weighed  five  pounds.  The  small  size  of  the  foetus  accounts  for  the  rapidity 
of  the  labor ;  and  yet  this  lady  had  enjoyed  good  health  during  her  preg- 
nancy, besides  having  reached  her  full  term. 

The  woman's  age  has  not  the  unfavorable  influence  upon  the  duration  of 
labor,  even  in  primiparse,  which  is  accorded  to  it  by  some  authors.  "  There 
has  always,"  says  Madame  Lachapelle,  "been  an  opinion  prevalent  on  this 
point  which  I  can  by  no  means  adopt ;  it  is,  that  the  dilatation  of  the  pas- 
sages is  more  difficult  in  women  advanced  in  years  than  in  others,  and 
there  is  not  an  accoucheur  who  does  not  dread  the  first  labor  in  a  female 
of  thirty  or  thirty-five  years  of  age  ;  nor  is  there  a  woman  in  that  condition 
who  does  not  anticipate  with  terror  the  hour  of  her  delivery.  My  expe- 
rience has,  however,  so  often  proved  the  fallacy  of  such  prejudices  that  1 
cannot  adopt  them. 

"No  doubt,  the  labor  is  often  slow  and  painful  in  middle-aged  women 
who  have  had  no  children,  yet  the  same  is  the  case  with  the  youngest.  I 
dare  affirm,  indeed,  that  there  is  no  more  difficulty  in  the  one  case  than  in 
the  other,  and  that  if  four  young  primiparous  females  out  of  ten  have  easy 
labors,  four  out  of  ten  if  the  oldest  will  also  be  delivered  with  promptitude 
and  facility." 


300  LABOR. 

§  G.  Of  the  Effect  of  Labor  upon  the  Mother  and  Child. 

a.  Effect  of  the  Labor  upon  the  Mother. —  Independently  of  the  numerous 
accidents  which  are  liable  to  occur,  and  which  will  be  studied  hereafter 
under  the  head  of  Causes  of  Dystocia,  the  parturient  process  has  a  decided 
effect  upon  the  physical  and  moral  condition  of  the  female,  which,  unfor- 
tunately, almost  uniformly  escapes  attention.  This  effect  may  be  exhibited 
in  both  the  first  and  second  stages,  and  even  continue  for  a  few  hours  or 
days  after  delivery. 

The  commencement  of  labor  is  preceded  in  many  females  by  a  state  of 
anxiety  and  prostration,  and  often  by  feelings  of  fear  and  disquietude. 
This  usually  ceases  after  the  first  pains  are  experienced,  all  the  powers  of 
the  organism  seeming  then  to  be  devoted  to  the  accomplishment  of  the  great 
function  about  to  be  performed.  All  others  are  modified  or  suspended,  the 
appetite  is  lost,  and  if  the  patients  have  eaten  shortly  before,  they  not  un- 
frequently  reject  all  that  has  been  taken  by  vomiting.  If  much  time  be 
occupied  by  the  process  of  dilatation,  they  weep,  and  become  irritable 
and  despairing. 

This  excitability  diminishes  as  soon  as  the  second  stage  commences,  and 
the  patient  begins  to  feel  that  her  labor  has  really  begun.  From  that  time 
her  attention  seems  concentrated  on  a  single  object,  and  she  is  indifferent 
to  everything  else.  During  the  expulsive  pains,  her  condition  approaches 
that  which  characterizes  inflammation  or  fever ;  thus,  the  circulation  is 
quickened  in  a  degree  which  seems  connected  with  the  force  of  the  contrac- 
tions ;  the  heat  and  moisture  are  sensibly  augmented,  and  the  red  and  even 
livid  features  sometimes  covered  with  profuse  perspiration  ;  again,  in  some 
cases  the  skin  may  be  dry  and  hot. 

The  intensity  of  the  pains  occasionally  throws  the  patient  into  a  state  of 
extreme  agitation,  and  so  disorders  her  faculties  that  she  commits  acts  of 
violence  upon  her  attendants. 

This  agitation,  which  is  very  moderate  when  the  labor  progresses  regu- 
larly, becomes  extreme  when  the  latter  is  retarded  or  prolonged  inordi- 
nately. The  beginning  of  each  pain  is  then  marked  by  an  almost  convul- 
sive trembling  of  the  extremities.  The  face  is  burning,  and  the  entire  body 
bathed  in  perspiration,  the  eye  is  fixed  and  haggard,  and  the  features 
changed  ;  the  unfortunate  sufferer  screams,  laments,  desires  to  die,  and  begs 
to  be  either  killed  or  relieved  of  her  agony.  The  well-marked  disorder  of 
the  intellectual  faculties  is  sometimes  carried  to  complete  delirium,  during 
which  the  patients  utter  the  most  extravagant  expressions.  Two  such  cases 
have  come  under  my  own  observation.  The  delirium  is  almost  always  pre- 
ceded  and  accompanied  by  great  loquacity,  and  the  pains  are  hardly  felt. 
I  knew  a  young  lady,  after  a  rather  lengthy  labor  attended  with  extreme 
suffering,  suddenly  to  cease  complaining,  assume  a  smiling  expression,  and 
after  a  few  incoherent  phrases,  to  sing  in  full  voice  the  grand  air  of  Lucia 
di  Lammermoor.  I  cannot  express  the  terrifying  effect  produced  by  this 
song  upon  myself  and  the  attendants.  (A  bleeding,  followed  by  the  imme- 
diate application  of  the  forceps,  had  the  effect  of  calming  the  patient,  and 
chere  was  no  recurrence  of  delirium.)  Montgomery  also  states,  that  he 
has  known  women  to  be  completely  delirious  for  a  few  moments,  just  as  the 
brad  was  escaping  from  the  mouth  of  the  womb. 


PHYSIOLOGICAL     PHENOMENA    OF     LABOR.  301 

These  great  disturbances  of  the  economy  are  not  confined  to  cases  of  very 
tedious  isibor,  for  the  same  symptoms  have  been  witnessed  in  very  short  onea 
with  powerful  and  very  rapid  pains.  The  cerebral  excitement  which  their 
violence  produces,  may  be  carried  even  to  the  point  of  insanity ;  so  thai 
medico-legal  jurists  have  accounted  for  infanticides  by  this  momentary  dis- 
order of  the  intellect,  which  would  otherwise  have  been  inexplicable. 

The  disorder  is  sometimes  confined  to  the  affective  faculties.  I  have  seen 
a  mother,  says  Ed.  Rigby,  after  a  very  short  and  painful  labor,  exhibit  an 
unconquerable  aversion  to  her  child,  and  express  herself  in  reference  to  it 
in  terms  which  contrasted  strangely  with  the  tender  and  affectionate  remarks 
which  she  had  uttered  but  a  few  moments  previously. 

These  disorders  of  the  intellectual  and  affective  faculties  generally  last 
but  a  short  time,  and  are  not  significant  of  great  danger;  sometimes,  how- 
ever, the  shock  to  the  system  is  so  great,  that  death  takes  place  suddenly, 
either  during  the  course  of  the  labor,  or  shortly  after  delivery.  A  poor 
woman,  in  the  Charity  Hospital,  says  Davis,  had  been  in  labor  for  five 
hours  ;  the  membranes  ruptured,  and  a  large  amount  of  water  escaped ;  the 
discharge  was  immediately  followed  by  a  feeling  of  great  weakness ;  having 
a  desire  to  go  to  stool,  she  sat  down  upon  a  chamber,  made  a  few  efforts, 
and  fell  fainting.  She  was  placed  in  the  horizontal  position  as  soon  as  pos- 
sible, but  had  hardly  been  replaced  in  bed  before  she  had  ceased  to  live. 
The  autopsy  revealed  nothing  which  would  account  for  the  death.  Denmau 
also  mentions  several  cases  of  sudden  death  during  labor,  which  it  was 
impossible  to  explain. 

In  some  of  these  instances,  however,  the  sudden  discharge  of  a  large 
amount  of  water  might,  to  a  certain  extent,  lead  us  to  attribute  the  morcal 
syncope  to  the  same  cause  which  is  thought  to  produce  it  so  often  after  de- 
livery :  namely,  the  sudden  afflux  of  a  great  quantity  of  blood  to  the 
abdominal  vessels,  which  had  been  suddenly  relieved  from  the  pressure  to 
which  they  were  subjected  during  pregnancy. 

An  undue  importance  has,  I  think,  been  attributed  to  this  too  rapid 
depletion  of  the  organ  as  explanatory  of  sudden  death  after  labor.  In  some 
instances,  it  may  have  all  the  influence  accorded  to  it,  though  it  is  certainly 
incapable  of  accounting  for  all  known  facts. 

The  violent  efforts  made  by  the  woman  in  the  second  stage  of  labor  may 
also  occasion  a  rupture  of  some  part  of  the  respiratory  organs.  This  ex- 
plains the  cases  of  emphysema  of  the  face,  neck,  and  upper  part  of  the 
breast,  mentioned  by  several  authors  (Martin,  of  Lyons).  In  a  serious  case 
related  by  M.  Depaul,  death  resulted  apparently  from  double  pulmonary 
emphysema  occurring  suddenly  during  the  violent  expulsive  efforts  of  a 
long  and  painful  labor. 

The  fatal  effect  of  the  process  of  parturition  upon  the  nervous  system  of 
the  mother,  after  as  well  as  during  labor,  cannot  be  mistaken  ;  and  I  believe 
with  Churchill  that  it  consists  in  a  shock  of  greater  or  less  intensity  to  the 
cerebro-spinal  system.  This  shock,  which  is  an  effect  of  the  extraordinary 
agitation  produced  by  parturition,  is  altogether  similar  to  that  occasioned 
by  extensive  wounds,  and  which  sometimes  destroys  unfortunate  workmen 
who  have  had  a  member  crushed  by  a  machine,  or  to  that  ]  rod  (iced  by  an 


302  LABOR. 

extensive  burn.  The  sudden  death,  which  neither  the  circumstances  of  the 
accident,  nor  the  lesions  discovered  at  the  autopsy  are  capable  of  explain- 
ing, is  attributed  by  surgeons  to  nervous  shock. 

Not  only,  says  the  author  just  cited,  may  such  a  nervous  shock  take  place 
in  certain  labors,  especially  difficult  ones,  and  have  a  disastrous  result,  but 
it  exists  to  a  greater  or  less  extent  in  almost  every  case.  Moderate  atten- 
tion will  make  this  manifest.  Thus,  after  an  ordinary  labor,  the  general 
sensibility  is  almost  always  extreme:  although  the  senses  are  more  acute 
than  usual,  the  eyes  have  lost  their  lustre,  and  are  weak  and  languishing  ; 
the  least  light  hurts  them,  as  the  slightest  sound  offends  the  ear ;  and  if  this 
extreme  delicacy  be  not  respected,  serious  accidents  may  ensue. 

Under  ordinary  circumstances,  patients  recover  from  this  slight  collapse 
after  a  few  hours'  rest ;  but  when  the  labor  has  been  protracted,  or  an  opera- 
tion, such  as  turning,  has  been  demanded,  the  symptoms  are  much  more 
severe.  The  patient  is  much  weaker,  and  the  expression  of  features  is  fixed 
and  dull ;  she  lies  motionless  in  bed,  with  closed  eyes,  or  opens  them  from 
time  to  time,  without,  however,  fixing  them  upon  any  object  in  particular ; 
she  pays  no  regard  either  to  her  child  or  to  herself;  the  limbs  are  in  a  state 
of  complete  relaxation  ;  the  pulse  is  sometimes  slow,  at  others  frequent  and 
irregular,  though  always  weaker  than  usual,  and  the  breathing  slow  and 
difficult,  or  quick  and  panting. 

The  patient  may  remain  in  this  condition  for  a  long  time,  and  recovers 
from  it  slowly  and  gradually.  If  the  shock  has  been  too  great,  she  may 
grow  Aveaker  and  weaker,  until  the  prostration  ends  in  death.  The  autopsy, 
under  these  circumstances,  fails  to  throw  any  light  upon  the  cause  of  death. 

This  singular  state  of  affairs  is  not  always  manifested  immediately  upon 
delivery  ;  for  sometimes  considerable  time  elapses,  during  which  the  patient 
expresses  herself  as  feeling  very  well,  then  suddenly  complains  of  unusual 
weakness,  exclaims  that  she  is  about  to  faint,  and  yet  is  unable  to  account 
for  the  cause  of  her  condition.  There  are  no  particular  abdominal  symp- 
toms, no  evidence  of  hemorrhage,  and  the  uterus  is  well  contracted ;  still 
the  disorder  increases,  the  pulse  grows  weaker,  the  face  becomes  pale  and 
assumes  a  cadaverous  expression,  and  the  patient  is  so  prostrated  as  to  be 
able  to  express  her  feelings  only  by  a  groan.  Suddenly  she  experiences  a 
sensation  of  violent  constriction  of  the  chest,  and  expires  before  anything 
can  be  done  for  her  relief. 

Opium,  says  Churchill,  has  seemed  to  me  the  most  effectual  remedy  in 
these  cases.  Five  drops  of  laudanum  may  be  given  every  half  hour,  then 
every  hour,  and  finally  at  longer  intervals.  It  appears  to  calm  the  general 
disturbance,  diminish  the  cerebral  shock,  and  give  to  the  whole  system  suf- 
ficient time  to  recover  its  exhausted  forces.  Small  quanties  of  wine  and 
brandy  may,  at  the  same  time,  be  given  at  intervals,  in  doses  sufficient  to 
assist  in  re-establishing  the  strength,  but  not  in  such  quantity  as  to  produce 
a  general  reaction.  The  induction  of  sleep  will  be  assisted  by  entire  quiet- 
ness of  both  body  and  mind,  and  when  so  fortunate  a  result  is  obtained,  the 
strength  is  recruited,  and  the  pulse  and  respiration  become  calm  ;  if,  on 
the  contrary,  the  prostration  continues,  the  case  is  one  of  the  most  danger- 
ous character,  and  demands  the  increased  use  of  external  and  internal  slim- 


MECHANICAL     PHENOMENA    OF     LABOR.  303 

ulants.  Ramsbotham  recommends  that  pressure  should  also  be  made  upon 
the  abdomen,  doubtless  with  the  object  of  preventing  the  afflux  of  fluids 
towards  the  abdominal  vessels. 

If  the  agitation,  spasm,  and  delirium,  of  which  we  have  spoken,  appear 
during  labor,  blood  should  be  taken  immediately  from  the  arm,  provided 
the  general  condition  of  the  patient  admit  of  it,  and  the  delivery  be  accom- 
plished as  soon  as  possible. 

The  same  course  is  also  indicated  by  the  sudden  occurrence  of  a  marked 
disorder  of  one  of  the  organs  of  the  special  senses,  —  amaurosis,  for  example. 

B.  The  effect  which  labor  may  have  upon  the  foztus  depends  upon  a  multitude 
of  circumstances,  most  of  which  will  be  studied  hereafter.  Thus,  having 
described  the  mechanism  of  labor  in  each  presentation,  we  shall  treat  of 
the  effect  which  each  is  liable  to  have  upon  the  health  and  life  of  the  child. 
The  various  causes  of  dystocia  are  quite  as  unfavorable  to  the  latter  as  to 
its  mother. 

We  have  but  these  observations  to  make  in  this  place;  namely,  that  all 
things  else  being  equal,  the  mortality  of  male  infants  is  much  greater  than 
that  of  females,  which  is  due,  as  we  have  said  before,  to  the  greater  size  of 
the  former,  and  the  proportionally  longer  duration  of  the  labor  in  conse- 
quence ;  the  extreme  slowness  of  this  process,  which  so  often  proves  fatal  to 
the  foetus,  has  this  unfortunate  effect  only  when  it  affects  the  second  or  ex- 
pulsive stage.  Until  the  membranes  are  ruptured,  and  even  until  the 
dilatation  is  completed,  the  labor  may  be  prolonged  indefinitely  without 
injury  to  the  foetus,  provided  a  certain  amount  of  fluid  remains  in  the  uterus. 

It  were  hardly  necessary  to  observe  that  any  cause  of  dystocia  is  liable  to 
affect  the  mother's  health  injuriously,  and  she  is  more  liable  to  consecutive 
inflammations  and  other  unfavorable  complications  of  labor  when  delivered 
of  a  boy  than  of  a  girl. 


80-4  LABOR.  K 

CHAPTER  III. 

OF  THE  MECHANICAL  PHENOMENA  OF  LABOR. 

ARTICLE  I. 

OF   THE    PRESENTATIONS   AND    POSITIONS. 

When  speaking  of  the  child's  attitude  in  the  uterine  cavity,  we  stated 
that  it  was  generally  so  situated  that  the  cephalic  extremity  formed  the 
most  dependent  part.  But  it  may  also  happen,  under  the  influence  of 
causes  hereafter  to  be  studied,  that  some  other  point  of  the  great  axis  shall 
correspond  to  the  uterine  neck :  that  is  to  say,  the  upper  or  cephalic  extre- 
mity, the  inferior  or  the  pelvic  extremity,  or  even  some  part  of  the  middle 
portion  or  trunk,  may  first  present  itself  at  the  superior  strait.  Now,  it  is 
very  evident  that  such  different  circumstances  of  presentation  must  neces- 
sarily influence  the  mechanism  of  the  labor,  as  also  the  facility  and  the 
promptness  of  the  delivery,  and  it  is  therefore  highly  important  to  understand 
well  all  those  diverse  situations  before  commencing  the  study  of  the  me- 
chanism proper.  This  study  comprises  the  presentations  and  positions,  as 
they  are  called ;  and  in  using  these  terms  we  wish  to  designate  by  the  word 
presentation  the  part  that  first  offers  at  the  superior  strait;  and  by  that  of 
position,  the  relations  of  this  presenting  part  with  the  different  points  of  the 
same  strait. 

The  older  accoucheurs  only  endeavored  to  recognize  the  presenting  part, 
without  investigating  its  relations  with  the  various  points  of  the  circumfer- 
ence of  the  strait ;  but  since  the  days  of  Solayres,  and  more  especially  since 
those  of  his  pupil  Baudelocque,  everybody  has  had  a  classification  of  his 
own  ;  and  the  number  of  presentations  and  positions,  considered  as  so  many 
separate  and  distinct  ones,  varied  with  each  author  who  wrote  on  the 
obstetrical  art. 

We  give,  in  the  following  tables,  the  classification  of  Baudelocque,  and 
the  principal  ones  of  those  who  have  succeeded  him. 


MECHANICAL  PHENOMENA  OF  LABOR. 


305 


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MECHANICAL    PHENOMENA     OF     LABOR. 


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308 


LABOR. 


CLASSIFICATION  OF  PROFESSOR  MOREAU. 


TWO  CLASSES. 


FIRST  ORDER. 
Presentation    of    the  -{ 

cephalic  extremity. 


SECOND  ORDER. 
Presentation    of    the  ■{ 
pelvic  extremity. 


THIRD  ORDER. 


FIRST  ORDER 

Accidental     artificial 
labor. 


1st  genus. 
Vertex  presentation. 


2d  gems. 
Face  presentation. 

3d  genus. 

Presentation  of    the 
sides  of  the  head. 
2  subdivisions. 
Right  side. 

_  Left  side. 


1st  position.  —  Left  occi- 
pito-ilium. 

2d  position. —  Right  oc- 
cipito-ilium. 


I  NATURAL  LABORS. 

1  ARTIFICIAL  LABORS. 

FIRST  CLASS.— Nat  URAL   Labors. 

anterior, 

transverse, 

posterior. 

anterior, 

transverse, 

posterior. 

3d    position. —  Occipito-pubic. 

4th  position — Occipi to-sacral. 

,   ,         ...  t>.   ,  ,         ( anterior. 

1st  position. —  Right 

mento-ilium. 


2d  position. —  Left 
mento-ilium. 


J  transverse, 
(  posterior, 
anterior, 
transverse, 
posterior. 


1st  position. — Lobulo-pubic. 

2d    position. — Left  lobulo-ilium. 

3d   position. — Right  lobulo-ilium. 

,    .  ...  T    e,  (  anterior. 

1st  position.  —  Left    sa- 

cro-ilium. 


1st  gents. 
Breech  presentation. 


2n  genus. 


1st  position. - 
2d  position. - 
3d   position - 


Lobulo-pubic. 
■Left  lobulo-ilium. 
-Right  lobulo-ilium. 


2d   position.— 
sacro-ilium. 


trans\  erse, 

posterior. 

t>.    ,  .         (  anterior, 
Right 

b  1  transverse, 

(  posterior. 

3d   position. —  Sacro-pnbic. 

4th  position. —  Sacro-sacral. 

1st  position. —  Left  calcaneo-ilium. 

2d   position. —  Right  calcaneo-ilium. 
Foot  presentation.     ]   3d  position. —  Calcaneo-pubic. 

-It  1]  position.  —  Calcaneo-sacral. 
i    1st  position. —  Left  tibio-ilium. 
J   2d    position.  —  Right  tibio-ilium. 
1   3d   position. —  Tibio-pubic. 
[  4th  position. —  Tibio-sacral. 
(  Single  genus. —  Presentation  of   the 
I       trunk.     (See  below.) 


3d  genus. 
Presentation  of 
knees. 


the 


natural 


Accidental 

labor. 
SECOND  CLASS.  — Artificial  Labors. 

1st  genus. 
Accidents  on  the  mo- 
ther's part. 
2n  genus. 
Accidents  on  the  part 
of  the  foetus. 


SECOND  ORDER 

Essentially 
labor. 


THIRD  ORDER 
Labors  which  are  the  ■ 

result  of  malforma- 
tion. 


f  SINGLE  GENUS. 

Presentation   of    the 
trunk, 
"tificial  "I   -  subdivisions. 

1st.  Right  side.    . 
[  2d.    Left  side.       .     . 

1st  genus. 
On  the  part  of  the  child. 

2d  genus. 
On   the  part  of   the 
mother. 


f  1<t  position. - 
\  2d  position. - 


■  Left  cephalo-ilium. 
Right  cephalo-ilium. 


f  1st  position. —  Left  cephalo-ilium. 
\  2d  position. —  Right  cephalo-ilium 


L 

APPENDIX,   OR  THIRD  CL.' SS.— Anomalies. 
Anomalies  either  in  the  seat,  ct  urse,  or  products  of  gestation,  or  lesions  of  the  womb. 


MECHANICAL    PHENOMENA    OF    LABOB.  309 

The  reader  will  see,  by  the  foregoing  table,  that  Bau.lelocque  primarily 
divides  the  foetus  into  two  extremities:  the  one  represented  by  the  apex  cf 
the  head,  the  other  by  the  feet,  knees,  or  breech ;  ajid  further,  that  the 
remainder  of  the  child's  surface  is  divided  off  into  foui  regions,  which  are 
again  subdivided  into  several  others.  After  having  deiermined  the  foetal 
regions,  the  presence  of  which,  at  the  superior  strait,  constituted  a  presenta- 
tion, it  was  equally  necessary  to  understand  the  positions.  For  that  pur- 
pose certain  points  of  departure  were  selected,  both  on  the  pelvis  and  on  the 
presenting  part  of  the  child.  Of  course,  these  points  varied  according  to 
the  presentation:  thus,  in  a  vertex  one,  Baudelocque  took  the  occiput  and 
forehead  as  the  points  on  the  foetal  head  ;  he  then  divided  the  pelvis  into  an 
anterior  and  a  posterior  half;  on  the  first  of  which  the  right  and  the  left 
cotyloid  cavities  and  the  symphysis  pubis,  and  on  the  second  the  right  and 
left  sacro-iliac  symphyses,  and  the  sacro-vertebral  angle,  were  selected  as 
the  points  of  departure ;  he  next  established  six  positions  of  the  vertex,  in 
each  of  which  the  occiput  corresponded  to  one  of  those  points  on  the  pelvis 
just  indicated. 

In  the  presentations  of  the  breech,  knees,  and  feet,  he  retained  the  same 
three  points  on  the  anterior  half  of  the  pelvis,  but  on  the  posterior  half  he 
only  adopted  one :  the  sacro-vertebral  angle.  On  the  foetus,  the  heels  were 
the  points  of  correspondence  in  foot  presentations,  the  sacrum  for  the  breech, 
and  the  front  surface  of  the  legs  for  those  of  the  knee.  Consequently,  but 
four  positions  were  admitted  for  either  the  breech,  feet,  or  knees. 

Lastly,  for  the  presentations  of  the  numerous  regions  indicated  by  the 
table  on  the  anterior,  posterior,  and  lateral  planes  of  the  foetus,  he  selected 
on  the  mother's  pelvis  the  two  extremities  of  the  antero-posterior  diameter 
(the  symphysis  pubis  and  the  sacro-vertebral  angle),  and  the  two  ends  of 
the  transverse  diameter,  as  the  points  of  departure,  so  that  he  pointed  out 
four  possible  relations,  that  is  to  say,  four  positions  for  each  one  of  these 
presentations.  Thus,  Baudelocque  admitted  altogether  one  hundred  and 
two  distinct  positions.  But  it  was  soon  ascertained  that  so  great  a  number 
was  whollv  useless  in  practice:  and  besides,  it  had  the  serious  disadvantage 
of  disgusting  pupils  with  the  study  of  midwifery.  The  classification  of 
Baudelocque  was  therefore  modified  to  some  extent,  and  we  have  succes- 
sively traced,  in  our  table,  the  principal  of  those  modifications  ;  still,  even 
after  adopting  the  latter,  the  obstetrical  art  was  yet  greatly  confused,  and  it 
remained  for  M.  Nsegele  to  simplify  this  branch  of  medical  science,  much 
more  than  it  had  ever  been  done  before  his  day.  To  him,  therefore,  wo 
must  attribute  this  honor,  as  also  to  Dubois,  and  Stoltz,  of  Strasbourg,  who 
first  endeavored  to  disseminate  throughout  France  the  views  of  the  Heidel- 
berg professor!  It  must  be  acknowledged,  however,  that  the  labors  of 
Madame  Laehapelle,  and  the  teachings  of  Ant.  Dubois,  have  not  been 
altogether  foreign  to  this  improvement. 

We  should  also  observe  that  the  classification  of  M.  Moreau  is  far  more 
simple  than  all  those  of  Baudelocque  and  his  followers;  indeed,  this  pro- 
fessor has  adopted  (as  seen  by  the  table)  most  of  the  ideas  upon  which  the 
arrangement  of  Nregele  is  founded,  and  we  only  regret  that  he  has  con- 
sidered the  presentations  of  the  sides  of  the  head  and  certain  of  the  position- 


310  LABOK. 

as  distinct,  which  we  hope  to  demonstrate  hereafter  d(  not  deserve  to  be  so 
regarded. 

In  fact,  there  is  no  region  of  the  child  which  may  not  present  at  the 
superior  strait  during  the  labor,  and  therefore,  if  we  are  to  consider  all  the 
points  of  its  surface  that  may  be  accessible  to  the  finger  as  so  many  distinct 
presentations,  their  number  would  be  very  considerable;  but  if,  on  the  con- 
trary, the  expression  is  only  applied  to  the  presence  of  a  region  large  enough 
to  occupy  the  whole  superior  strait,  more  especially  to  one  requiring  a 
notable  difference  either  in  the  mechanism  of  its  spontaneous  expulsion,  o* 
in  the  manoeuvres  to  be  resorted  to,  this  number  would  then  be  much  more 
limited. 

Upon  such  opinions,  advocated  long  since  by  Madame  Lachapelle  and 
Ant.  Dubois,  M.  Na?gele  has  founded  the  following  classification,  which  is 
now  admitted  and  taught  by  Dubois  and  Stoltz  in  France,  namely,  three 
principal  regions  are  distinguished  in  the  foetus:  1.  The  head,  or  cephalic 
extremity;  2.  The  pelvis,  or  pelvic  extremity;  and  3.  The  trunk;  either 
of  which  parts  may  offer  first  at  the  superior  strait. 

When  the  cephalic  extremity  presents,  it  is  ordinarily  flexed  on  the  chest, 
and  the  vertex  then  advances  first ;  but  it  may  also  be  extended  or  thro  ,vn 
backwards  on  the  posterior  plane  of  the  foetus,  in  which  case  the  face 
engages  first.  We  have  therefore  to  distinguish  between  a  vertex  presenta- 
tion and  one  of  the  face,  for  the  mechanism  of  labor  is  very  different  in  the 
two.  When  the  pelvic  extremity  presents,  the  legs  are  usually  flexed  on 
the  thighs,  and  the  latter  on  the  abdomen ;  but  it  may  happen,  from  a 
variety  of  causes  that  we  shall  hereafter  designate,  that  these  divers  parts, 
which  are  usually  folded  up  in  this  manner,  are  separated  from  each  other: 
thus,  they  sometimes  engage  altogether  in  the  excavation  ;  at  others,  either 
during  the  course  of  the  labor  itself,  or  some  time  before,  the  inferior  mem- 
bers stretch  out  and  lay  along  the  front  of  the  body,  and  the  nates  then 
descend  alone.  Again,  the  legs  may  be  swept  down  either  by  the  gush  of 
the  waters,  or  by  some  other  cause,  and  engage  first ;  hence,  in  this  latter 
instance,  if  the  deflexion  of  the  lower  members  is  complete,  the  feet  are  the 
first  to  clear  the  vulva ;  but  if,  on  the  contrary,  the  thighs  be  extended,  and 
the  legs  remain  flexed  on  them,  the  knees  will  be  the  first  to  show  them- 
selves at  the  external  orifice. 

Now  it  must  be  evident,  on  the  least  reflection,  that  these  latter  circum- 
stances can  effect  no  modification  in  the  mechanism  of  the  labor  itself,  and 
accoucheurs  are  certainly  in  error  in  considering  them  as  so  many  distinct 
presentations  ;  consequently,  we  shall  describe  them  under  the  single  title  of 
the  presentation  of  the  pelvic  extremity;  merely  remarking  that,  when  tl  i* 
extremity  presents,  all  its  constituent  elements  may  happen  to  engage 
together  at  the  same  time,  or  they  may  be  separated,  and  then  the  breech, 
or  the  knees,  or  feet,  will  offer  first  at  the  vulva. 

But  before  proceeding  any  further,  we  will  follow  the  example  of  M. 
Dubois  (from  whom  this  article  is  borrowed  almost  verbatim),  by  laying 
down  precisely  the  limits  of  the  foetal  regions  embraced  in  the  double 
expression  of  the  cephalic  and  the  pelvic  extremi  y:  thus,  when  the  head  or 
the  nelvis  piesents  at  the  superior  strait,  it  usually  does  so  nearly  "plumb:'1 


MECHANICAL     PHENOMENA    OF    LABOR.  31] 

that  it  to  say,  the  long  diameter  of  the  foetus  is  almost  parallel  t<  the  axis 
of  this  strait ;  so  that  the  sagittal  suture  in  the  vertex  presentations,  the 
facial  median  line  in  those  of  the  face,  and  the  fissure  between  the  nates  in 
those  of  the  pelvic  extremity,  occupy  very  nearly  the  centre  of  the  abdo- 
minal strait. 

But  very  numerous  exceptions  to  this  rule  occur,  because  the  mobility 
of  the  foetus  in  the  uterine  cavity,  and  the  frequency  of  the  uterine  obli- 
quities, may  cause  the  child's  long  diameter  to  be  inclined  forwards,  back 
wards,  or  towards  the  sides.  Hence,  it  is  evident  that  the  presenting  part, 
participating  in  this  inclination,  will  not  be  so  regularly  placed  as  usual ; 
thus,  if  it  were  a  vertex  presentation,  and  the  inclination  were  anterior,  the 
summit  would  no  doubt  descend,  though  it  would  be  accompanied  by  the 
forehead  in  consequence  of  this  defective  position;  or,  if  the  inclination 
were  on  the  posterior  plane,  instead  of  the  forehead,  we  should  have  the 
occiput  or  occasionally  even  the  neck.  Again,  if  it  is  lateral,  that  is,  if  the 
foetus  is  bent  towards  one  side,  the  vertex  and  one  side  of  the  head  may 
be  recognized  at  the  same  time ;  and  the  sagittal  suture,  instead  of 
corresponding  to  the  axis  of  the  superior  strait,  will  then  be  found  either 
behind  or  in  front,  according  to  the  direction  of  the  inclination ;  but  such 
inclinations  do  not  deprive  the  vertex  presentation  of  its  character,  they 
only  convert  it  into  a  defective  or  irregular  presentation. 

The  observations  just  made  in  regard  to  vertex  presentations  equally 
apply  to  those  of  the  face  and  breech,  and  we  may  therefore  have  regular 
and  irregular  ones  of  these  parts  just  in  the  same  way.  To  resume,  we  shall 
include  in  the  class  of  vertex  presentations,  all  those  designated  by  Baude- 
locque  under  the  names  of  presentations  of  the  occiput,  nape,  and  lateral 
parts  of  the  head;  in  face  presentations,  those  of  the  forehead,  chin,  cheeks, 
front  and  sides  of  the  neck  ;  and  in  the  breech,  those  of  the  sacrum,  genital 
parts,  front  of  the  thighs,  &c. ;  whence  all  the  surface  comprised  between 
the  sinciput  and  the  shoulders  belongs  to  the  cephalic  presentations,  and 
that  between  the  summit  of  the  nates  and  the  haunches  is  referred  to  the 
pelvic  ones. 

If  we  now  take  off  all  the  foetal  parts  included  in  the  cephalic  and  pelvic 
extremities,  there  will  only  remain  the  trunk  proper:  that  is,  the  portion 
extending  from  the  shoulders  to  the  hips,  and  this  part  may  also  present 
the  first*  Now  with  regard  to  this,  Madame  Lachapelle  has  long  since 
remarked  that,  when  the  trunk  offers  at  the  superior  strait,  it  always  does 
so  by  one  of  its  sides:  that  is  to  say,  the  anterior  or  the  posterior  median 
line  of  the  body  never  corresponds  to  the  axis  of  the  superior  strait.  There- 
fore, she  divided  the  trunk  into  two  lateral  halves,  either  of  which  may 
come  down  first;  hence  there  are  two  trunk  presentations,  one  of  the  right 
lateral  plane,  the  other  of  the  left  lateral  plane;  the  whole  anterior  and 
posterior  right  moieties  being  included  in  the  first,  and  the  same  parts  on 
the  left  being  embraced  in  the  second ;  and  as  the  shoulder,  which  is  then 
the  most  prominent  part,  is  nearly  always  found  at  the  centre  of  the  superior 
strait,  when  the  lateral  planes  oiler  first,  that  skilful  midwife  designated 
them  as  presentations  of  the  shoulder.  M.  Dubois,  however,  still  retains  the 
name  of  the  presentations  of  the  lateral  regions;  and  these,  like  the  others. 


312  LABOR. 

may  either  be  regular  or  irregular.  They  are  regular  when  Jke  lateral  line 
is  directly  at  the  centre  of  the  abdominal  strait,  but  irregular  where  the 
anterior  or  the  posterior  region  of  the  trunk  occupies  this  strait  in  a  grea't 
measure,  owing  to  the  child  being  more  or  less  inclined  forward  or  back- 
ward ;  and  it  is  to  such  irregularities  that  we  must  refer  all  those  presenta- 
tions of  the  back,  loins,  front  of  the  chest  and  abdomen,  described  by  the 
older  authors. 

On  the  whole  then  we  admit  five  presentations,  viz.,  one  of  the  vertex, 
one  of  the  face,  one  for  the  pelvic  extremity,  one  for  the  right  lateral  plane, 
and  one  for  the  left  lateral  plane.  Besides  the  presentations,  Baudelocque, 
and  all  those  who  followed  him,  described  a  great  number  of  positions;  in 
each  of  which,  according  to  their  account,  the  mechanism  of  the  labor  was 
different.  But  M.  Nsegele,  in  consequence  of  a  better  conducted  study  of 
this  mechanism,  has  succeeded  in  changing  entirely  this  branch  of  the 
science,  and  has  further  proposed  a  reform  in  the  positions,  at  least  as 
important  as  what  he  has  already  made  in  the  classification  of  the  presenta- 
tions. Thus,  he  simply  divides  the  pelvis  into  two  lateral  halves,  the  right 
and  the  left,  and  these  form  the  only  points  of  departure  at  the  superior 
strait ;  on  the  foetus,  the  points  admitted  by  Baudelocque  are  retained.  For 
instance,  in  a  vertex  presentation,  the  occiput  may  offer  at  any  one  point 
whatever  of  the  left  lateral  half  of  the  superior  strait,  thereby  constituting 
the  first  position  of  the  vertex ;  or  it  may  correspond  in  a  similar  way  with 
the  right  lateral  half,  thus  producing  the  second  position;  further,  as  the 
mechanism  is  just  the  same,  whether  the  occiput  be  at  first  at  the  front,  in 
the  middle,  or  behind,  we  shall  only  consider  these  circumstances  as  so  many 
varieties  of  the  same  position  ;  which  shades  or  varieties,  in  the  great 
majority  of  cases,  do  not  change  the  mechanism  of  the  natural  labor  in 
any  wise,  and  therefore  do  not  deserve  to  be  received  as  important  elements 
in  a  classification,  but  of  which,  however,  more  account  should  be  taken 
than  appears  to  have  been  done  by  M.  Na^gele,  for  they  may  be  usefully 
recalled  in  explanation  of  certain  anomalies,  as  also  for  successful  interven- 
tion in  some  cases  of  difficult  labor. 

What  has  just  been  stated  concerning  the  vertex  equally  applies  to  the 
positions  of  the  face  and  breech;  since  in  the  former  the  chin  may  be 
directed  towards  some  point,  either  on  the  right  or  the  left  lateral  half  of 
the  pelvis  ;  and  in  the  latter  the  sacrum  may  have  a  similar  relation  with 
some  point  of  its  right  or  left  half;  therefore  we  adopt  a  first,  or  the  right 
mento-iliac,  and  a  second,  or  the  left  mento-iliac  position  for  the  face;  and 
likewise  for  the  breech  we  have  a  first,  or  the  left  saero-latcral,  and  a  second, 
or  the  right  saero-lateral  position.  Lastly,  the  two  presentations  of  the 
trunk  have  each  two  positions:  for  example,  the  right  side  of  the  foetus  pre- 
senting, the  head  may  happen  to  be  placed  either  above  some  point  on  the 
left  lateral  moiety,  or  over  a  similar  part  on  the  right  one.  Hence,  there 
are  two  positions:  first,  the  left  cephalo-ilidc,  and  second,  the  right  cephalo- 
iliac;  or,  if  the  child's  left  side  presents  in  the  same  way,  the  head  may  be 
either  to  the  left  or  the  right,  thus  giving  rise  to  two  new  positions,  the  left 
*nd  the  right  cephalo-iliac  position. 


MECHANICAL    PHENOMENA    OF    LABOR. 


313 


[Perhaps  it  would  be  better  to  adopt  M.  Jacquemier's  expression  and  say,  that 
when  a  shoulder  presents,  the  acromion  is  directed  sometimes  toward  the  left  and 
sometimes  toward  the  right  side  of  the  pelvis.  Hence  we  have  two  positions,  left 
acromio-iliac  and  right  acromio-iliac.  The  same  idea  is,  therefore,  expressed, 
whether  we  say  that  the  right  shoulder  presents  in  a  left  cephalo-iliac  or  in  a  left 
acrumio-iliac  position,  but  the  assumption  of  the  acromion  as  the  point  of  reference 
makes  the  nomenclature  clearer  and  more  uniform.] 

There  is  scarcely  a  necessity  for  adding  that  the  anterior,  transverse,  and 
posterior  varieties,  admitted  for  vertex  positions,  are  also  retained  for  the 
t\\  o  fundamental  ones  of  the  face,  the  breech,  and  the  right  and  left  sides. 


1.  Vertex  presentation, 


SUMMARY. 

Left  occipito-iliac, 

Right  occipito-iliac, 
Riu;ht  mento-iliac, 


3  varieties. 


anterior, 

transverse, 

posterior. 

1  anterior, 
transverse, 
posterior. 


3  varieties, 


2.  Presentation  of  the  face,   - 


3.  Presentation  of  the  breech, 


Left  mento-iliac, 


Left  sacro-iliac, 


Right  sacro-iliac, 


T  anterior, 
J  transverse, 
(  posterior. 
(  anterior, 


4.  Presentation  of  the  right  f  Left  cephalo  or  acromio-iliac, 
.     .     .  [  Right  cephalo  or  acromio-iliac, 


I  posterior. 

1  anterior, 
transverse, 
posterior. 
(  anterior, 
3  varieties,  \  transverse, 
(  posterior. 


lateral  plane, 

Presentation   of 

lateral  plane, 


the     left  f  Left  cephalo  or  acromio-iliac. 


f  Le 
|Ri 


ght  cephalo  or  acromio-iliac,  .     .    I 


anterior, 

transverse, 

posterior. 


We  would  observe,  however,  that  in  shoulder  presentations  the  varieties 
of  position  are  far  less  important  than  in  the  other  presentations,  and  that 
it  matters  very  little  whether  the  acromion  and  the  head  be  more  or  less  in 
front  or  behind. 

But  all  the  presentations  and  positions  just  indicated  have  not  the  same 
frequency,  nor  are  they  all  equally  favorable  to  the  spontaneous  expulsion  of 
the  child.  There  are  some  even,  such  as  the  positions  of  the  trunk,  in  which 
this  is  most  generally  impossible,  but  there  is  no  one,  however,  in  which  it 
absolutely  cannot  take  place ;  therefore,  we  shall  have  to  examine  the 
mechanism  of  natural  labor  in  each  of  these  presentations  successively, 
reserving  to  ourselves  the  privilege  of  reverting  in  the  fourth  part  of  this 
work  to  those  which  usually  offer  an  insurmountable  difficulty;  and  as  the 
vertex  presentations  are  the  most  frequent  and  favorable  of  all,  we  shall 
commence  with  a  description  of  them. 


314  LABOR. 


ARTICLE    II. 

OF    THE   VERTEX    PRESENTATION. 

This  presentation  is  far  more  frequent  than  all  the  others  put  together: 
thus,  in  20,517  births  reported  by  Madame  Boivin,  19,810  children  were 
born  by  the  vertex;  and  in  2020  cases  reported  by  M.  Dubois,  there  wire1 
1913  of  this  variety.  Again,  when  the  vertex  presents,  the  occiput  is  much 
oftener  directed  towards  the  left  than  the  right  side :  for  instance,  in  the 
1913  cases  just  cited,  M.  Dubois  noticed  1367  left  occipito-iliac,  and  only 
546  right  occipito-iliac  positions.  Nor  are  the  three  varieties  pointed  out 
for  each  position  equally  frequent :  thus,  in  the  1367  cases  where  the  occi- 
put was  directed  to  the  leftside,  it  was  inclined  forward,  that  is,  towards  the 
left  cotyloid  cavity,  1355  times,  and  only  12  t;mes  backwards,  in  the  direc- 
tion of  the  left  sacro-iliac  symphysis,  or  nearly  so.  But  in  the  546  instances 
of  right  occipito-lateral  positions  an  opposite  result  was  observed ;  for  the 
occiput  was  only  found  55  times  at  the  right  acetabulum,  but  491  times  at 
the  right  sacro-iliac  symphysis  ;  so  that,  contrary  to  the  generally  received 
opinion,  the  posterior  right  occipito-iliac  position  is  much  more  frequent 
than  the  anterior  one.  We  have  given  these  results  as  ascertained  by  M. 
Dubois  himself,  because  they  are  entirely  consonant  with  our  own  observa- 
tions, and  with  those  of  M.  Stoltz,  of  Strasbourg. 

In  one  hundred  cases  of  vertex  presentations,  it  has  been  found  on  an  aver- 
age, says  M.  Nsegele,  that  in  seventy  the  occiput  is  directed  in  front  and  to 
the  left,  and  behind  and  to  the  right  in  thirty  ;  he  considers  the  other  varie- 
ties as  being  very  rare  and  altogether  exceptional. 

In  these  results,  no  question  seems  to  be  made  of  the  varieties  we  have 
designated  as  the  transverse  ones,  and  it  is  highly  probable  that  they  have 
been  approximately  added  to  one  of  the  four  preceding  groups,  for  these 
positions  are  not  very  unusual ;  indeed,  I  have  often  met  with  them  myself 
at  the  Clinique. 

"These  positions,"  says  Madame  Lachapelle,  "are  more  frequent  than 
those  where  the  occiput  corresponds  to  the  left  sacro-iliac  symphysis  ;  "  and, 
I  will  add,  than  those  where  it  is  at  the  right  acetabulum  ;  also,  that  the 
left  transverse  occipito-iliac  position  is  more  common  than  the  opposite  one. 

§  1.  Causes. 

As  we  have  already  spoken  of  the  cause  of  the  vertex  presentations,  when 
treating  of  the  child's  attitude  in  the  uterine  cavity,  we  shall  not  now  go 
over  the  same  ground,  but  will  only  remark,  that  most  accoucheurs  attri- 
bute the  frequency  of  the  dependent  position  of  the  head  to  its  own  specific 
weight;  whilst  M.  Dubois,  after  having  endeavored  to  refute  the  general 
opinion,  has  considered  this  position  as  the  consequence  of  an  instinctive 
determination  of  the  foetus  itself.  (See  art.  Foetus.)  However,  it  is  not  at 
all  difficult  to  explain  why  the  left  anterior,  and  the  right  posterior  occipito- 
iliac  varieties  are  the  most  frequent  of  any,  since  it  is  evidently  owing  to 
the  presence  of  the  rectum  on  the  left  side.  The  habitual  distention  of  this 
bowel  by  fecal  matters  obliges  the  forehead  or  occiput  to  turn  towards  the 
front  whenever  either  of  these  parts  is  directed  backwards  and  to  the  left 


MECHANICAL,   PHENOMENA    OF   LABOR.  315 

It  is  far  more  difficult  to  say  why  the  occiput  is  so  much  more  frequently 
found  in  front  than  behind,  although  this  very  probably  depends  on  the 
same  causes  as  those  which  determine  the  vertex  presentation. 

Thus,  the  posterior  half  of  the  head  weighs  far  more  than  the  anterior, 
and  the  same  is  true  of  the  trunk ;  further,  when  the  woman  is  standing, 
sitting,  or  on  her  knees,  or  even  lying  on  the  side,  the  anterior  wall  of  the 
abdomen  is  the  most  dependent  portion,  towards  which  the  child's  heaviest 
parts,  that  is  to  say,  its  posterior  plane,  must  necessarily  tend. 

§  2.  Diagnosis. 

[The  presentation  of  the  vertex  and  its  positions  may  be  determined  by  three 
different  kinds  of  examination,  riz.,  palpation  of  the  abdomen,  auscultation,  and  the 
vaginal  touch. 

Palpation  of  the  Abdomen.—  If  the  hands  be  placed  upon  the  abdomen  and  the 
walls  of  the  uterus  depressed,  parts  of  the  foetus  may  be  felt  and  with  a  little  prac- 
tice distinguished  quite  readily. 

To  obtain  the  best  results  from  this  method,  the  woman  should  lie  upon  her  back 
with  the  walls  of  the  abdomen  as  much  relaxed  as  possible,  and  by  gentle  pressure 
be  accustomed  to  the  contact  of  the  hands.  At  the  outset  it  is  not  uncommon  for 
the  examination  to  be  interrupted  by  a  contraction  of  the  womb,  which,  of  course, 
should  be  allowed  to  subside.  After  some  trials,  however,  the  abdominal  muscles 
and  the  walls  of  the  uterus  yield  to  the  pressure,  so  that  the  hand  which  explores 
the  hypogastric  region  is  enabled  to  distinguish  with  some  precision  a  voluminous, 
hard  and  rounded  mass  which  recalls  exactly  the  size  and  form  of  the  head  of  a 
child.  Above  it  may  often  also  be  recognized  the  entire  dorsal  region  of  the  foetus, 
so  that  it  only  becomes  a  question  between  a  presentation  of  the  vertex  and  one  of 
the  face. 

A  circumstance  which  may  embarrass  physicians,  who  have  but  little  experience 
in  this  kind  of  research,  arises  from  the  fact,  that  near  the  end  of  pregnancy,  and 
especially  in  primiparous  cases,  it  often  happens  that  the  entire  head  has  descended 
into  the  cavity  of  the  pelvis  and  necessarily  escapes  detection  by  the  hand  which 
confines  itself  to  a  superficial  examination  of  the  hypogastric  region.  In  this  case, 
if  the  ends  of  the  fingers  be  placed  above  the  body  of  the  pubis  and  pressed  down- 
ward as  though  to  push  the  walls  of  the  abdomen  into  the  lesser  pelvis,  the  head 
of  the  child  will  soon  be  felt  filling  the  entire  cavity.  I  have  in  hundreds  of  in- 
stances succeeded  in  this  way  in  diagnosing  the  vertex  presentation,  and  that  with- 
out causing  either  pain  or  a.ccident. 

The  presentation  being  determined,  if  the  accoucheur  can  feel  to  which  side  the 
back  of  the  child  is  turned,  the  palpation  has  enabled  him  to  diagnose  both  presen- 
tation and  position. 

In  the  occipito-posterior  positions,  the  greatest  width  of  the  womb  is  still  at  the 
upper  part,  as  stated  in  the  account  of  the  normal  condition  ;  but  the  fundus  is  not 
so  evenly  rounded  unless  the  quantity  of  fluid  be  very  great:  most  commonly,  Bays 
M.  Stoltz,  an  arched  projection  may  be  detected  at  the  fundus,  and  beneath  it  a 
sensible  depression.  The  anterior  plane  of  the  foetus  being  diracted  forward,  the 
inequalities  formed  by  its  extremities,  which  are  discovered  with  difficulty  in  ocei- 
pito-anterior  positions,  are  detected  more  readily. 

A  certain  degree  of  importance  ought,  therefore,  to  be  accorded  to  this  kind  of 
exploration,  though  we  should  be  careful  not  to  over-estimate  its  value.  In  the  most 
9imple  cases  we  are  sometimes  liable  to  be  deceived,  and  a  mistake  becomes  easy 
when  the  walls  of  the  abdomen  are  thick  or  the  quantity  of  waters  great.  Finally, 
it  should  be  understood  that  in  some  women  the  uterus  is  so  readily  excited  to  con- 
traction, that  it  becomes  impossible  to  depress  its  walls  sufficiently  to  arrive  at  any 
result.     Still  another  consideration   which    lessens  the  value  of  palpation  is,  tliar., 


oil)  LABOR. 

though  it  may  be  easy  before  labor  cornea  on,  it  becomes  difficult  tr  even  linpuisilln 
a*  that  time  ;  all  which  is  readily  explained  by  the  severe  pains  which  it  provokes 
aud  the  facility  with  which  it  excites  the  contraction  of  the  uterus. 

Auscultation.  —  The  diagnosis  of  the  presentations  and  positions  of  the  vertex 
may  also  be  determined  by  auscultation.  As  Prof.  Depaul  has  treated  this  subject 
thoroughly  in  his  Traite  d' Auscultation  Obstetricale,  1  will  merely  state  here,  that  in 
the  presentation  of  the  cephalic  extremity,  the  maximum  intensity  of  the  pulsations 
of  the  heart  are  heard  above  a  horizontal  line  passing  through  the  umbilicus.  Tc 
this  law  there  are  very  few  exceptions  in  a  normal  condition  of  the  pelvis,  and 
whatever  relates  to  deformities  need  not  detain  us  here. 

Auscultation  is  not  less  important  in  order  to  determine  the  position.  As  in  thn 
foetus  the  lungs  are  flattened  against  the  vertebral  column,  the  sound  of  the  heart 
is  transmitted  to  the  ear  through  the  dorsal  region  whose  curvature  is  applied 
against  the  walls  of  the  uterus;  therefore,  as  the  greatest  intensity  of  the  sounds  of 
the  heart  is  perceived  over  the  spinal  column,  and  as  both  it  and  the  posterior 
fontanelle  are  directed  toward  the  same  side,  we  learn  where  the  occiput  is  situated. 
In  the  left  anterior  occipito-iliac  position  the  heart  beats  in  front  and  to  the  left, 
whilst  in  the  right  posterior  occipito-iliae  position  it  is  heard  behind  and  to  the 
right.  The  same  reasoning  indicates  certainly  the  point  at  which  the  head  ought 
to  be  heard  for  each  particular  position.  To  avoid  being  deceived  by  the  data 
which  auscultation  supplies,  we  ought  always  to  determine  and  fix  precisely,  not 
i  he  point  where  the  heart  is  heard  merely,  but  the  point  where  the  sound  is  loudest. 
Without  this  precaution  auscultation  would  be  as  deceptive  as  useful  in  the  endeavor 
to  determine  the  position.] 

Vaginal  Touch.  —  Before  labor,  and  even  during  the  last  few  months  of 
gestation,  the  vertex  can  often  be  recognized  as  presenting;  while  in  every 
ill  lur  presentation  the  part  that  offers  first,  from  being  irregular,  voluminous, 
and  badly  adapted  to  the  form  of  the  inferior  uterine  segim  .'t,  and  of  the 
superior  strait,  is  always  so  high  up,  and  separated  from  the  uterine  wall  by 
so  large  a  quantity  of  waters,  as  to  be  scarcely  accessible  to  the  finger. 

The  vertex,  on  the  contrary,  presenting  a  rounded  spheroidal  surface, 
reposes,  almost  without  the  intervention  of  any  liquid,  on  the  uterine  walls, 
nay,  even  presses  them  before  it,  and  engages  in  the  excavation,  descending 
in  some  cases  as  low  down  as  the  floor  of  the  pelvis.  Hence,  whenever  the 
vertex  presents,  it  is  easily  detected  through  the  inferior  portion  of  the 
incline  wall,  unless,  indeed,  it  should  be  retained  at  the  superior  strait  by  a 
considerable  inclination  of  the  womb,  or  by  a  malformation  of  the  pelvis. 

In  a  word  (and  this  reflection  appears  to  me  essentially  practical),  when- 
ever the  accoucheur  does  not  easily  reach  the  presenting  part  in  the  last 
few  days  of  the  gestation,  and  more  particularly  during  the  first  periods  of 
lalioi,  he  should  examine  the  woman  very  carefully;  for  it  is  then  exceed- 
ingly probable  that  the  head  is  not  at  the  superior  strait;  or,  even  where 
the  cephalic  extremity  does  present  flexed,  there  is  reason  to  fear  a  wrong 
direction,  or  perhaps  a  faulty  organization  of  the  head  or  pelvis;  all  which 
circumstances  may  subsequently  require  the  intervention  of  our  art.  We 
would,  however,  remark,  that  in  women  who  have  borne  children  the  head 
often  continues  very  high  up  until  the  end  of  gestation,  and  does  not  get 
below  the  superior  strait  until  labor  sets  in.1 

1  A  variety  of  circumstances  may  occur  inwards  the  end  of  gestation,  or  at  the  begin- 
ning of  the  Labor,  dependent  on  causes  wholly  foreign  to  any  faulty  positions,  whereby 
a  might  happen  that  no  part  could  be  detected  by  the  touch:  thus,  1.  It  is  sometimes 
observed  in  women  who  have  had  several  children,  and  in  whom    the   funduB  uteri  is 


MECHANICAL     PHENOMENA    OF    LABOR. 


317 


Supposing  the  labor  has  begun,  if  the  finger  be  introduced  through  the 
cervix  uteri,  it  will  immediately  encounter  a  rounded,  smooth,  and  resistant 
surface,  which  is  the  anterior  side  of  the  head ;  and  then,  by  directing  the 
index  a  little  further  upwards  and  backwards,  in  the  direction  of  the  sacro- 
vertebral  angle,  it  will  come  into  contact  with  a  membranous  interval,  that 
is,  with  the  sagittal  suture. 

A  vertex  presentation  is  now  ascertained  ;  and  the  next  step  is  to  make 
out  the  position.  For  that  purpose  we  first  assure  ourselves  of  the  direction 
of  the  suture,  and  if  it  prove  to  be  oblique,  running  from  before  backwards, 
and  from  the  left  towards  the  right,  the  position  must  either  be  the  left 
anterior,  or  the  right  posterior  occipito-iliac  one;  but,  on  the  contrary,  if  it 
be  oblique  in  the  other  diameter,  the  position  will  either  he  the  right  anterior 
or  the  left  posterior  occipito-iliac,  &c. 

The  direction  being  once  determined,  we  have  then  only  to  find  out  where 
the  occiput  lies,  to  complete  the  diagnosis ;  therefore,  the  finger,  by  raising 
up  the  margin  of  the  os  uteri,  follows  the  sagittal  suture  until  it  reaches  a 
fontanelle,  which  is  to  be  distinguished  by  the  characters  hitherto  described. 
(See  Head  of  the  Foetus  at  Term.) 

§  3.  Mechanism. 

The  mechanism  by  which  the  expulsion  of  the  child  is  accomplished  in 
positions  of  the  vertex  is  very  nearly  the  same  in  all  cases  where  the  occiput 
corresponds  with  one  of  the  points  of  the  left  lateral  half  of  the  pelvis ;  but 
it  differs  in  some  respects  from  that  observed  in  the  positions  designated  as 
the  right  occipito-iliac  ones. 

We  must,  therefore,  examine  it  in  both  of  these  positions  ;  and  as,  among 
the  admitted  varieties,  there  are  two,  the  anterior  in  the  left  occipito-iliac, 
and  the  posterior  in  the  right  occipito-iliac,  which  are  almost  constantly 
met  with,  Ave  shall  take  them  up  successively  as  the  types  of  our  description. 

1.  Mechanism  of  Natural  Labor  in  the  left  Anterior  Occipito-iliac  Position, 
(The  first,  or  the  left  occipito-cotyloid  position 
of  authors.) — In  this  position,  the  occiput  cor- 
responds to  the  left  ilio-pectineal  eminence,  the 
forehead  to  the  right  sacro-iliac  symphysis,  and 
the  sagittal  suture  lies  in  the  direction  of  the 
left  oblique  diameter  of  the  pelvis.  (In  order 
to  avoid  unnecessary  repetitions  and  delays,  we 
premise,  once  for  all,  that  we  shall  designate 
that  oblique  diameter  which  runs  from  the  left 
toAvards  the  right  side,  and  from  before  back- 
wards, as  the  left  oblique,  and  the  one  passing 
from  the  right  towards  the  left,  and  from  in 
front  posteriorly,  as  the  right  oblique  diameter.) 
The  posterior  fontanelle  is  found  to  the  left 
and  in  front,  the  anterior  one  is  behind  and  to 
the  right.  The  dorsal  plane  of  the  foetus  looks 
Btrongly  inclined  forwards;  2.  In  cases  of  twins;  3.  In  breech  presentations;  4.  AVliere 
there  is  a  large  amount  of  water;  6  Where  the  uterus  is  not  oval  at  its  inferior  pari  ; 
6.  Where  the  head  is  hydrocephalus  ;  and  lastly,  where  the  pelvis  is  narrow.  (Ntegble 
'.ran slated  by  Pi'jnt.) 


Fig.  75. 


Representing  the  head  In  the  left  an> 
terior  occipito-iliac  positiou. 


318  LABOR. 

forwards  and  towards  the  left  side ;  while  its  anterior  plane  is  directed 
backwards  and  to  the  right;  the  right  shoulder  is  in  front  and  to  the  right 
side;  the  left  one  is  behind  and  towards  the  mother's  left. 

Before  the  bag  of  waters  is  ruptured,  the  child's  head  is  slightly  flexod 
on  the  front  of  the  chest,  and  the  following  are  the  relations  of  its  diameter 
with  those  of  the  superior  strait:  the  occipito-frontal  corresponds  to  the  left 
oblique  of  the  strait,  and  the  bi-parietal  to  the  right  oblique  j1  and,  of  course, 
the  occipito-frontal  circumference  of  the  head  is  parallel  with  the  periphery 
of  the  abdominal  strait,  and  the  axis  of  this  strait  corresponds  with  the 
trachelo-bregmatic  diameter2  of  the  head. 

When  the  membranes  are  ruptured,  a  variable  quantity  of  liquid  escapes  ; 
then  the  uterus  contracts  and  applies  itself  more  directly  to  the  foetal  trunk; 
nevertheless,  as  but  little  fluid  passes  away  in  vertex  positions  at  this  time, 
there  usually  remains  a  sufficient  quantity  of  it  to  render  the  pressure  of 
the  uterine  walls  on  the  child  far  from  being  immediate. 

After  the  rupture,  the  object  of  the  contractions  is  to  expel  it  from  the 
womb ;  the  foetus  becomes  more  curved  anteriorly,  and  its  superior  and 
inferior  extremities  more  closely  folded  up  ;  and  from  that  moment,  properly 
speaking,  the  mechanical  phenomena  of  labor  begin. 

[The  various  movements  communicated  to  the  foetus  during  lahor  tend  to  facili- 
tate its  expulsion,  as  will  appear  from  the  description  of  them  about  to  be  given 
under  the  usual  term  of  the  stages  of  labor. 

*  We  may  remark,  however,  with  M.  Dubois,  that  this  last  relation  is  not  absolutely 
exact.  For  instance,  if  the  head  of  the  foetus  at  term  be  found  at  the  superior  strait, 
so  that  the  occipito-frontal  diameter  is  parallel  with  the  left  oblique,  the  shape  of  the 
head  will  prevent  the  bi-parietal  one  from  corresponding  with  the  right  ohlique 
diameter.  In  fact,  in  this  position  the  posterior  extremity  of  the  bi-parietal  diameter 
is  at  the  left  sacro-iliac  symphysis,  but  the  anterior  extremity,  instead  of  terminating 
opposite  the  ilio-pectineal  eminence,  is  found  very  near  the  middle  of  the  horizontal 
branch  of  the  pubis. 

2  M.  Nsegele  and  Professor  Dubois  (who  adopts,  at  least  in  part,  the  views  of  the 
Heidelberg  Professor)  do  not  believe  that  the  head  presents  at  the  superior  strait,  in 
the  majority  of  cases,  so  regularly  in  all  its  relations  as  we  have  just  described,  for 
they  say  the  head  does  not  offer  perpendicularly  to  the  plane  of  the  strait,  but  on  the 
contrary,  in  an  oblique  direction;  whence  the  right  parietal  protuberance,  which  is 
also  the  anterior  one,  would  be  lower,  relatively  to  the  plane,  than  the  left ;  and  the 
bi-parietal  suture,  instead  of  being  found  in  the  direction  of  the  axis  of  the  head, 
would  be  a  little  behind  it,  according  to  M.  Dubois,  and  would  even  look  towards  the 
second  bone  of  the  sacrum,  agreeably  to  M.  Naagele. 

But,  notwithstanding  these  imposing  authorities,  we  Relieve  the  occipito-frontal  cir- 
cumference is  closely  parallel  to  the  plane  of  the  strait  in  most  cases,  although  the 
parietal  boss  is  certainly  one  of  the  most  dependent  parts  of  the  head,  and  the  finger 
first  strikes  upon  it  in  practising  the  vaginal  examination.  But  those  facts  by  which 
M.  Nsegele  sustains  his  views  prove  just  the  contrary;  because  the  plane  of  the  abdominal 
strait,  being  directed  very  obliquely  downwards  and  forwards,  the  portion  of  the  head 
in  contact  with  the  anterior  arch  of  the  pelvis  should  be  its  most  dependent  part; 
and  further,  the  finger  first  encounters  the  anterior  parietal  protuberance,  because  the 
introduction  take3  place  under  the  symphysis  pubis,  that  is  to  say,  almost  perpen- 
dicularly to  the  superior  strait,  and  therefore  the  index  can  only  reach,  in  a  very 
oblique  direction,  the  anterior  portion  of  the  head,  whose  greatest  circumference  ife 
parallel  to  the  plane  of  the  superior  strait. 


MECHANICAL   PHENOMENA    OF   LABOR. 


310 


Five  principal  stages  have  hitherto  been  reckoned  in  vertex  present  xticns ;  they 
are,  following  the  order  in  which  they  occur:  1st.  flexion;  2d.  descent;  3d.  rota- 
tion; 4th.  extension  or  disengagement ;  5th.  restitution.  To  these  five  stages  we 
think  it  proper  to  add  a  sixth  for  the  expulsion  of  the  body.  At  the  end  of  thi9 
chapter  (see  Recapitulation  of  the  Mechanism  of  Labor),  we  shall  state  more  fully 
the  reasons  which  induce  us  to  alter  the  number  of  stages  as  usually  described, 
remarking  only  for  the  present,  that  we  think  it  gives  the  advantage  of  a  classifica- 
tion which  is  both  more  rational  and  applicable  to  every  presentation.  In  the 
account  of  the  mechanism  of  expulsion  for  each  presentation  we  shall,  therefore, 
describe  six  stages. 

It  will  be  seen  that  this  innovation  does  not  call  for  a  change  in  the  generally 
received  opinions,  inasmuch  as  we  have  only  to  reunite  the  fifth  and  sixth  stages 
to  restore  the  old  classification.] 

These  phenomena,  or  stages  of  the  mechanism,  are  five  in  number,  as 
follows :  in  the  first,  the  head  is  more  strongly  flexed  on  the  chest ;  in  the 
second  it  traverses  all  the  space  between  the  superior  and  inferior  straits, 
and  reaches  the  floor  of  the  pelvis ;  there  it  experiences  a  movement  of 
rotation  which  carries  the  occiput  behind  the  symphysis  pubis,  thus  con- 
stituting the  third  period  ;  in  the  fourth,  the  head  undergoes  the  process  of 
extension,  by  which  all  the  superior  and  anterior  parts  of  the  vertex  and 
face  become  completely  disengaged  at  the  anterior  commissure  of  the 
perineum ;  and  then,  after  its  perfect  expulsion,  the  child's  cephalic  extre- 
mity performs  a  fifth  and  last  movement,  designated  by  Baudelocque  as  the 
period  of  restitution,  but  which  M.  Gerdy  has  proposed  to  name  the  exterior 
rotation. 

A.  First  Stage,  or  Stage  of  Flexion. — After  the  rupture  of  the  membranes, 
the  foetal  trunk,  being  compressed  on  all  sides,  transmits  to  the  head,  through 
the  spine,  the  impulse  derived  from  the  uterine  contractions.     The  head, 
being  forcibly  pressed  on,  has  a  tendency  to 
clear  the  uterine  orifice,  and  to  engage  in  the  Fw.  76. 

excavation.  But  it  then  encounters  resistances, 
either  from  the  os  uteri,  which  is  not  yet  suffi- 
ciently dilated,  or  from  the  superior  strait,  or 
the  walls  of  the  excavation;  and  being  thus 
placed  between  a  power  and  a  resistance,  the 
head  must  naturally  become  still  more  flexed 
on  the  chest;  in  fact,  the  force  of  expulsion 
transmitted  by  the  vertebral  column,  falling 
upon  the  occipital  foramen,  that  is.  on  a  point 
much  nearer  to  the  occiput  than  the  chin,  must 
uecessarily  (the  resistance  being  equal  at  the 
two  extremities  of  the  occipito-mental  diameter) 
act  more  powerfully  on  the  occiput  than  on  the   The  ,',,i,,, '"  ,h" sam"  >' "*i,ion-  """'s'1 

....  ,  .  ,  more  flexed. 

chin ;   in  other  words,  must  press  down   the 

occiput  into  the  excavation.    But,  by  depressing  this  part,  the  chin  is  forced 

to  ascend,  thus  producing  the  flexion  of  the  head.1 

1  In  orler  to  prove  that  t lx.  >  movement  of  flexion  results  from  the  position  of  the 
occipital  foramen,  relatively  to  the  chin  and  occiput,  which  represents  the  two  extre- 
mities of  the  lever  whereon  the  spine  is  articulated,  let  us  suppose,  for  a  moment,  that 


820  LABOR. 

The  head  being  in  this  way  forcibly  flexed,  its  relations  are  changed . 
that  is,  the  occipito-bregmatic  diameter  has  taken  the  place  of  the  occipito- 
frontal, and  has  become  parallel  to  the  left  oblique  of  the  strait ;  but  the 
bi-parietal  remains  unaltered  :  the  occipito-bregmatic  circumference  is  now 
on  a  level  with  the  periphery  of  the  strait,  and  the  axis  of  the  pelvis,  which 
before  corresponded  with  the  trachelo-bregmatic  diameter,  now  traverses  the 
head  very  nearly  in  the  direction  of  the  occipito-mental  diameter. 

This  movement  of  flexion,  therefore,  evidently  places  the  child's  head  in 
the  most  favorable  position  for  its  passage,  by  constraining  it  to  offer  its 
smallest  diameters  to  those  of  the  pelvis. 

B.  Second  Stage,  or  Stage  of  Descent. — The  head,  pressed  on  by  the  con- 
tractions, enters  the  excavation  and  reaches  the  floor  of  the  pelvis.  In 
making  this  descent,  the  occiput  presses  in  front  against  the  internal  and 
anterior  face  of  the  body  of  the  ischium,  the  obturator  internus  muscle,  and 
the  external  obturator  vessels  and  nerves,  which  pass  out  through  the  upper 
part  of  the  obturator  foramen  ;  while  the  forehead  or  bregma  presses  behind 
on  the  internal  border  of  the  psoas  and  pyramidal  muscles,  the  sciatic 
plexus  of  nerves,  together  with  the  gluteal  and  the  internal  pudic  vessels 
and  nerves.  The  left  side  of  the  head  likewise  comes  into  mediate  relation 
with  the  same  parts,  and  also  glides  over  the  anterior  surface  of  the  rectum. 
But  the  descent  of  the  head  is  not  completed  until  the  occipito-bregmatic 
circumference  is  nearly  parallel  to  the  plane  of  the  inferior  strait :  that  is, 
when  the  two  parietal  protuberances  have  attained  this  level.  Now,  it  is 
evident  that,  to  reach  this  point,  the  left  parietal  boss  (which  is  found 
behind)  must  traverse  the  whole  anterior  face  of  the  sacrum,  whilst  the 
anterior  one  has  only  to  clear  a  much  shorter  space ;  the  first  must  there- 
fore describe  the  arc  of  a  much  larger  circle  than  the  second.  Perhaps  a 
more  exact  idea  of  the  actual  movement  of  the  head  will  be  formed  by 
imagining  the  anterior  extremity  of  the  bi-parietal  diameter  to  remain 
nearly  stationary  in  front  and  to  the  right,  while  its  posterior  extremity 
descends  rapidly  and  traverses  the  whole  posterior  plane  of  the  excavation. 

the  vertebral  column  is  attached  to  the  occiput  alone,  when  it  is  evident  that  the  latter 
only  will  descend;  on  the  other  hand,  let  it  be  made  to  the  chin,  which -will  then 
descend  the  first,  and  lastly  let  it  be  done  at  the  centre  of  the  interval  between  these 
two  extremes,  and  an  equilibrium  will  be  produced,  the  same  as  results  from  equal 
weights  or  resistances  placed  in  the  dishes  of  a  balance  having  equal  arms.  But 
where  the  articulation  takes  place  nearer  one  extremity  than  the  other,  the  descent 
will  occur  at  this  extremity,  just  as  it  would  happen  in  the  above-cited  balance,  if, 
without  altering  anything  else,  the  arms  were  rendered  unequal  in  their  length. 

To  conclude,  lest  the  foregoing  should  not  satisfactorily  explain  the  phenomenon,  I 
propose  the  following  rationale:  the  head,  urged  on  by  the  uterine  contraction,  com- 
municated to  it  by  the  spine,  meets  with  resistance  from  the  os  uteri,  which  is  not  yet 
sufficiently  dilated.  Let  us  change,  for  an  instant,  the  order  of  forces,  making  the 
vertebral  articulation  a  fulcrum,  and  the  opposition  on  the  part  of  the  neck  the  power; 
low,  this  power  is  evidently  equal  in  all  points  of  the  periphery  of  the  neck;  but  let 
us  observe  that,  as  the  interval  between  the  chin  and  the  occipital  foramen  is  greater 
than  that  betwixt  the  latter  and  the  occiput,  the  resistance  against  the  chin  operates 
on  a  longer  lever  than  that  against  the  occiput,  and  consequently  the  first  must  be  the 
more  powerful  of  the  two,  and  therefore  it  forces  the  chin  to  ascend.  Biit  raising  the 
latter  has  the  same  effect  as  depressing  the  occiput:  that  is,  still  producing  a  flexion 
tf  the  head. 


MECHANICAL  PHENOMENA  OF  LaBOR.  321 

C.  Third  Stage,  or  Stage  of  Rotation. — The  head,  being  arrested  by  the 
floor  of  the  pelvis,  executes  a  movement  of  rotation,  during  which  the  occi- 
put passes  from  left  to  right  behind  the  symphysis  pubis,  or  rather  behind 
the  left  ischio-pubic  ramus,  and  the  bregma  rotates  into  the  concavity  "f 
the  sacrum,  though  remaining  a  little  towards  the  right. 

The  posterior  superior  part  of  the  right  parietal  bone  then  appears  plainly 
under  the  pubic  arch ;  the  posterior  fontanelle  is  behind  the  ischio-pubic 
ramus ;  and  the  sagittal  suture  crosses  the  coccy-pubal  diameter  very 
obliquely.  Being  forced  on  by  the  energetic  contractions  of  the  womb,  the 
vertex  then  depresses  the  soft  parts  of  the  perineum,  and  by  gradually  dis- 
tending them,  succeeds  in  converting  the  pelvic  floor  into  a  part  of  a  canal 
which  prolongs  the  posterior  wall  of  the  pelvis  downwards  and  backwards. 
It  is  during  this  time  that  the  rotation  is  accomplished :  that  is,  the  sagittal 
suture  becomes  parallel  with  the  antero-posterior  diameter  of  the  inferior 
strait.  The  occiput  engages  in  the  arch  of  the  pubis,  and  projects  beyond 
the  lower  part  of  the  symphysis,  until  the  back  part  of  the  neck  comes  into 
contact  with  it,  when  the  anterior  progression  of  the  occiput  is  arrested. 

D.  Fourth  Stage,  or  Stage  of  Extension. — Just  at  the  moment  when  the 
occiput  engages  in  this  manner  in  the  pubic  arch,  the  shoulders  and  upper 
part  of  the  body  enter  the  excavation,  and  in  engaging  there,  the  fetal 
trunk,  which  is  flexible,  accommodates  itself  to  the  direction  of  the  canal, 
and  consequently  bends  over  a  little  on  its  posterior  plane. 

[The  head  then  presses  upon  the  perineum,  distending  it  and  transforming  it  into 
a  groove  or  gutter  which  conducts  the  occiput  to  the  vulvar  opening,  so  that  if  the 
patient  be  uncovered  the  accomplishment  of  the  fourth  stage  may  be  witnessed  by 
the  observer.  At  each  contraction  the  head  descends  and  the  perineum  is  elongated ; 
then,  as  the  pain  subsides  the  perineum  contracts,  at  the  same  time  pressing  the 
head  a  little  upward.  Finally,  during  a  fresh  effort  the  vulva  opens  and  the  occiput 
6hows  itself  beneath  the  arch  of  the  pubis.  At  this  moment  the  head  is  still  flexed, 
but  soon  the  nucha  seems  to  fix  itself  behind  the  pubis,  and  the  head,  by  executing 
a  movement  of  extension,  escapes  completely  from  the  vulvar  orifice,  bringing  sue 
cessively  into  view  after  the  occiput,  the  vertex,  forehead,  nose,  mouth,  and  chin  ; 
the  latter,  which  is  the  last  to  emerge,  remains  applied  against  the  posterior  com- 
missure of  the  vulva  and  directed  toward  the  anal  region. 

This  movement  has  received  what  seems  to  us  a  curious  explanation,  for,  accord- 
ing to  the  commonly  accepted  view,  the  pressure  transmitted  by  the  spinal  column 
to  the  head  is  divided  at  the  occipital  foramen  into  two  forces,  one  of  which  is 
applied  to  the  occiput,  and  the  other  to  the  chin.  Therefore,  when  the  occiput  is 
engaged  beneath  the  pubic  arch,  the  portion  of  force  which  is  transmitted  to  it  is 
lost  upon  the  point  of  contact  between  the  vertebral  column  and  the  posterior  part 
of  the  pubis,  whilst  the  force  directed  upon  the  chin  continuing  to  act  depresses  it, 
causing  it  to  depart  from  the  breast  and  thus  producing  the  movement  of  extension 

Now,  this  explanation  seems  to  us  fallacious;  for  is  it  not  evident  that  whilst  the 
occiput  is  beneath  the  pubic  arch,  all  the  soft  parts  which  make  up  the  perineum 
press  the  anterior  part  of  the  head  against  which  they  are  applied  upward  and 
backward,  so  that  the  movement  of  flexion  is,  at  this  juncture,  at  its  utmost  limit? 

Our  own  view  of  the  disengagement  of  the  head  is  as  follows:  The  body  descends 
into  the  cavity  of  the  pelvis,  whilst  the  head  is  depressing  and  distending  the 
perineum,  and  the  chin  remains  applied  to  the  breast  not  merely  until  the  moment 
when  the  occiput  takes  its  place  behind  the  pubic  arch,  but  even  until  the  bregma 
makes  its  appearance  at  the  posterior  commissure  of  the  vulva.  Then  it  is  that  the 
21 


322 


LAROR. 


perineum  acts  like  an  elastic  splint  which,  on  the  one  hand,  presses  the  head  up- 
ward beneath  the  pubic  arch,  -whilst  on  the  other  it  slips  rapidly  over  the  face  which 
it  leaves  uncovered,  and  retracts  toward  the  coccygeal  region  where  it  is  attached 

The  disengagement  of  the  occiput  and  vertex  begins  only  when  the  head  is  pressed 
downward  sufficiently  by  the  body;  but  at  this  moment  the  perineum,  which  unti' 
then  was  1  ut  passively  distended,  resumes  its  action  and  retracts  as  just  stated, 
imparting  to  the  whole  head,  whilst  slipping  over  the  face,  a  movement  of  extension 
which  has  the  arch  of  the  pubis  for  its  centre.  Therefore,  it  is  only  in  this  second 
period  of  the  process  of  disengagement  of  the  vertex,  that  the  movement  of  exten- 
sion is  truly  evident. 

If  the  perineum  were  entirely  absent,  the  head  would  disengage  at  the  outlet  of 
the  inferior  strait,  without  exhibiting  its  movement  of  extension.  In  the  normal 
condition,  however,  and  especially  in  primiparse,  the  perineum,  converted  into  an 
elongated  gutter,  arrests  the  downward  progress  of  the  head  and  directs  it  forward 
as  upon  an  inclined  piano. 

Do  we  not  also  know  that  in  breech  cases,  especially  in  primiparas,  the  pelvic 
extremity  in  emerging  from  the  vulva  is  directed  just  as  obliquely  upward  and 
forward  as  the  lateral  flexion  of  the  body  will  allow?  This  flexion,  which  no  one 
will  deny  to  be  produced  by  the  soft  parts  of  the  perineum,  is,  in  our  opinion,  suffi- 
cient to  prove  that  the  movement  of  extension  in  delivery  by  the  vertex  is  effected 
only  by  the  curvature  and  elasticity  of  the  genital  passages,  for,  if  the  movement 
of  the  head  at  this  time  is  very  extended,  it  should  be  attributed  to  the  great 
mobility  of  the  articulations  which  permits  the  occiput  to  rise  up  in  front  of  the 
pubis.  In  breech  cases  the  same  phenomenon  occurs,  though  the  extent  of  motion 
is  greatly  restricted  by  the  rigidity  of  the  spinal  column  in  the  lumbar  region.] 

Whatever  explanation  be  accepted,  if  we  observe  what  takes  place  during 

this  movement  of  extension,  the  following  points 
are  seen  successively  to  appear  at  the  anterior 
commissure  of  the  perineum,  viz.,  the  bi-pari- 
etal  suture,  the  bregma  (or  fontanelle),  the 
coronal  suture,  the  nose,  mouth,  and,  last  of 
all,  the  chin.  During  this  process,  the  sub- 
occipito-bregmatic,  the  sub-occipito-frontal, 
and  the  sub-occipito-mental  diameters  succes- 
sively pass  the  antero-posterior  diameter  of 
the  inferior  strait.  As  soon  as  the  occipito- 
bregmatic  circumference  is  beyond  the  vulva, 
the  anterior  border  of  the  perineum,  yielding 
to  its  natural  elasticity,  retracts  strongly, 
slips  over  the  face,  and  embraces  the  neck ; 
and  just  at  that  moment  the  head,  which  was 
before  forcibly  turned  up  in  front  of  the  mons 
veneris,  falls  back  from  its  own  specific  weight 
towards  the  anus. 

E.  Fifth  Stage,  or  Stage  of  Exterior  Rotation.  (Restitution.)  — The  head 
remains  for  a  few  seconds  in  this  position,  and  then  it  is  seen  to  describe  a 
nf'tli  and  last  movement,  namely,  the  occiput  inclines  towards  the  interna) 
Burface  of  the  left  thigh,  and  the  face  turns  towards  the  right  thigh.  This 
process  is  usually  denominated  the  restitution,  for  the  following  reason- 
Before  the  researches  of  M.  Gerdy,  it  was  generally  supposed  that  when 


Fig.  77. 


Tim  head  Is  seen  in  various  degrees 
of  extension,  the  nape  of  the  neck  rest- 
ing first  behind,  ami  then  under,  the 
fymphysis  pubis. 


MECHANICAL  PHENOMENA  OF  LABOR.  323 

the  head  executed  its  movemeut  of  rotation  within  the  pelvis,  the  trunk 
did  not  participate  therein,  and  that  the  operation  could  only  take  place 
through  the  aid  of  a  certain  degree  of  torsion  in  the  neck ;  and,  further, 
that  the  head  becoming  completely  disengaged,  the  neck  untwisted,  and  the 
head  was  restored  to  its  natural  relations  with  the  trunk. 

M.  Gerdy  was  the  first  to  demonstrate  the  fauliiness  of  this  explanation; 
for,  in  fact,  the  trunk  does  participate  in  the  head's  rotation,  in  such  a  way 
that  the  shoulders,  which,  in  the  beginning  of  labor,  corresponded  to  the 
oblique  diameter,  are  nearly  transverse  after  this  movement  (the  right 
shoulder,  nevertheless,  remaining  always  a  little  more  in  front  than  the 
left).  The  shoulders  then  reach  the  inferior  strait  in  a  transverse  position, 
presenting,  therefore,  their  great,  or  bis-acromial  diameter,  to  the  smallest 
one  of  this  strait;  but  here  they  encounter  some  resistance,  under  the  influ- 
ence of  which  the  rotation  is  effected  in  the  opposite  direction  to  that  of  the 
head;  the  right  shoulder,  passing  from  the  right  side  towards  the  left, 
approaches  the  apex  of  the  pubic  arch,  while  the  left  one  gets  into  the 
perineal  concavity,  and  the  head,  being  free  externally,  necessarily  follows 
the  movement  communicated  to  the  shoulders. 

The  rotation  of  the  head  is  not  therefore  an  isolated  movement  peculiar 
to  itself,  as  Baudelocque  supposed*  but  one  secondary  to  the  rotation  of  the 
shoulders. 

I  must  remark,  however,  that,  in  some  cases,  the  head  has  appeared  to 
me  to  execute  a  double  movement ;  for,  immediately  after  its  expulsion,  it 
turns  very  slightly ;  the  occiput  passing  a  little  to  the  left,  the  forehead 
towards  the  right ;  after  remaining  some  seconds  in  this  position,  it  then 
undergoes  the  secondary  movement  just  described,  which  is  due  to  the  rota- 
tion of  the  shoulders.  The  first  of  these  movements  has  already  seemed  to 
me  to  result  from  the  untwisting  of  the  neck,  and  is  the  true  movement  of 
restitution  of  Baudelocque. 

F.  Sixth  Stage,  or  Stage  of  Expulsion  of  the  Body. — The  shoulders  present 
at  the  inferior  strait  soon  after  the  head,  and,  as  we  have  just  stated,  nearlv 
always  in  a  transverse  position.  The  right  one  gets  under  the  right  ischio- 
pubic  ramus,  while  the  left  one  lies  in  front  of  the  left  sacro-sciatic  lio-a- 
ment.  The  bis-acromial  diameter  is  rarely  found  in  the  direction  of  the 
antero-posterior  diameter  of  the  inferior  strait.  The  anterior  or  sub-pubic 
shoulder  is  the  first  to  appear  in  the  vulvar  Assure ;  although,  as  a  general 
rule,  the  posterior  one,  after  having  traversed  the  perineal  curve,  is  first 
disengaged  at  the  anterior  commissure  of  the  perineum,  and  the  right  one 
is  subsequently  delivered.1 

1  Contrary  to  the  generally  received  opinion,  M.  P.  Dubois  supposes  that  the  anterior 
shoulder  is  the  first  delivered.  That  is  certainly  true  in  a  great  number  of  cases,  but 
we  have  most  usually  observed  the  opposite  fact;  besides,  there  is  a  theoretical  view 
which  militates  in  favor  of  our  opinion,  that  is,  the  left  shoulder,  being  placed  in  con- 
tact with  the  posterior  plane  of  the  excavation,  is  situated,  much  more  than  the  ante- 
rior one,  in  the  direction  of  the  uterine  axis,  or  the  axis  of  the  superior  strait,  and 
therefore  being  subjected  to  a  more  energetic  uterine  impulse,  consequently  must  be 
delivered  first;  further,  it  was  necessary  this  should  be  so,  as  the  posterior  shoulder 
has  much  the  longer  course  to  traverse.  Again,  if  I  might  refer  to  my  own  observa 
tions.  I  would  say  that  in  women  who  have  before  borne  children,  more  especially  ir 


824  LABOR. 

During  the  disengagement  of  the  shoulders,  the  fottus  bt corals  Hexed  on 
its  right  lateral  region  so  as  to  accommodate  itself  to  the  curvature  in  the 
pelvic  canal ;  and  very  soon  after  the  remainder  of  the  trunk  is  expelled, 
sometimes  describing  a  very  prolonged  spiral  course  in  its  passage. 

2.  Mechanism  of  Natural  Labor  in  the  right  Posterior  Occipito-iliac  Posi- 
tion.    (The  fourth  of  Baudelocque,  and  the  third  of  M.  Capuron.) 

In  the  vast  majority  of  cases,  the  mechanism  of  labor  in  this  position 
scarcelv  differs  from  that  just  described,  and  therefore  we  only  need  allude 
here  to  the  principal  peculiar  phenomena  of  the  travail,  without  repeating 
all  the  preceding  details. 

It,  likewise,  is  composed  of  five  periods,  or  stages  ;  before  the  membranes 
are  ruptured,  the  diameters  of  the  head  correspond  with  the  same  diameters 
of  the  pelvis,  as  in  the  foregoing  case,  and  the  only  difference  to  be  re- 
marked is,  that  the  occiput  corresponds  to  the  right  sacro-iliac  symphysis, 
and  the  forehead  to  the  left  ilio-pectineal  eminence.  The  child's  posterior 
plane  looks  backwards  and  towards  the  mother's  right,  while  its  anterior 
plane  is  in  front  and  to  her  left ;  its  left  side  is  placed  in  front  and  on  the 
right,  its  right  side  behind  and  to  the  mother's  left. 

A.  First  Stage,  or  Stage  of  Flexion. — The  head  is  flexed  by  the  same 
forces  as  in  the  preceding  case,  and  this  flexion  determines  similar  changes 
in  the  relations  of  its  diameters  with  those  of  the  pelvis. 

B.  Second  Stage,  or  Stage  of  Descent. — This  stage  presents  nothing  worthy 
of  particular  notice. 

C.  Third  Stage,  or  Stage  of  Rotation. — The  head  having  reached  the  floor  of 
the  pelvis,  undergoes  a  movement  of  rotation,  in  consequence  of  which  the 
occiput  traverses  the  whole  right  lateral  moiety  from  behind  forwards,  in 
such  a  way  that  it  passes  successively  towards  the  right  extremity  of  the 
transverse  diameter,  behind  the  cotyloid  cavity  and  under  the  right  ischio- 
pubic  ramus,  while  the  forehead,  or  bregma,  revolving  in  an  inverse  direc- 
tion, goes  from  before  backwards  towards  the  hollow  of  the  sacrum  ;  and 
thus,  the  position  which  was  originally  occipito-posterior,  becomes  converted 
into  an  occipito-pubic,  or  anterior  one,  and  the  labor  then  terminates  just 
as  it  does  in  those  cases  where  the  occiput  was  primitively  in  front. 

[d.  Fourth  Stage,  or  Stage  of  Disengagement.  —  This  presents  nothing  peculiar. 

e.  Fifth  Stage,  or  Stage  of  Restitution.  —  The  movement  in  this  case  is  entirely 
analogous  to  that  already  described  in  connection  with  the  left  anterior  occipito- 
iliac  position,  and  is  due  to  the  same  causes.  It  is  the  left  shoulder,  however, 
which  gets  behind  the  arch  of  the  pubis,  and  the  occiput  is  directed  toward  the 
right  thigh. 

F.  Sixth  Stage,  or  Stage  of  Expulsion  of  the  Body. —  This  takes  place  under  the 
e  inditions  already  described.] 

Irregularities  in  the  Disengagement. — In  some  instances,  which  are  rare, 
however,  this  conversion  does  not  take  place,  and  the  occiput  remains  be- 
hind until  the  termination  of  the  labor.  The  delivery  is  then  concluded 
in  the  following  manner:  the  head  is  strongly  flexed  on  the  chest,  and  re- 

those  who  have  suffered  from  rupture  of  the  perineum  in  former  labors,  the  posterior 
Bhjulder  is  the  first  delivered;  and,  on  the  contrary,  in  primiparse,  the  sub-pubic  one 
hid  the  precedence,  the  other  btxng  retained  by  the  resistance  from  the  soft  partp. 


Plate  V 


Fi§3. 


<"...J5v„.^ 


iS&s*" 


PLATE   V. 

Fig.  i. 

Section  of  the  Frozen  Body  of  a  Woman  in  labor  during  the  period  of  Expulsion. 

a.  Aorta,  d.  Duodenum.  F.  Bag  of  Waters.  M.  Stomach.  L.  Liver. 
H.  Bladder.  Pa.  Pancreas.  n.  Urethra,  r.  Rectum.  v.  p.  Vena  portae. 
PL  Placenta,     o.  e.  o.  e.  External  Os  Uteri,     o.  i.  o.  i.  Internal  Os  Uteri. 

Fig.  2. 

Relations  of  the  Muscular  Floor  of  the  Pelvis  to  the  Last  Stage  of  Labor. 

/.  Upper  Margin  of  the  Vaginal  Ring.  2.  Ischio-perineal  Ligament  and 
Superficial  transverse  Muscle.  P.  Perineal  body.  A.  Anus,  flattened  and 
carried  back  towards  the  Coccyx. 

Fig.  3. 

Engagement  of  the  Head. 

u.    Urethra.      a.    Anus.       //.    Bladder.      2  k.    Second    Sacral    Vertebra 
r.  Rectum. 

Fig.  4. 
Commencing  Expulsion  of  the  Head. 


MECHANICAL     PHENOMENA    OF     LABOR.  325 

tains  its  oblique  position  ;  the  forehead,  corresponding  to  the  body  of  the 
left  pubis,  first  reaches  the  inferior  strait,  and  the  left  coronal  boss  then 
engages  under  the  pubic  arch,  where  we  can  sometimes  distinguish  the 
superciliary  ridge  just  below  the  symphysis;  and  I  even  saw  the  upper  eye- 
lid in  one  case.  But  though  the  forehead  first  Fia  78# 
appears  at  the  exterior,  the  occiput,  urged  on  by 
the  spine,  which  transmits  the  force  of  the  uterine 
contraction,  traverses  the  whole  curvature  of  the 
perineum  (which  is  greatly  distended  in  such 
instances),  and  becomes  disengaged  the  first  at 
the  anterior  commissure.  While  the  occiput  is 
thus  passing  over  the  anterior  surface  of  the  sa- 
crum and  perineum,  the  coronal  boss  and  eye- 
brow, that  originally  appeared  at  the  vulva, 
reascend  and  become  concealed  behind  the  sym- 
physis. 

The  occiput  is  scarcely  clear,  when  the  peri- 
neum by  gliding  Over  the  inclined    plane  formed       Disengagement  of  the  head  in   the 
,  ,  „    ,,  ,  i-i  occipito-posterior  positions. 

by  the  nape  or  the  neck,  retracts  strongly,  and 

thus  facilitates  the  subsequent  delivery  of  the  anterior  portions  of  the  head  ; 
therefore,  the  head  may  be  observed  to  undergo  the  process  of  extension 
around  the  nape  as  a  centre,  and  to  appear  below  the  symphysis  in  the  fol- 
lowing order :  namely,  the  anterior  fontanelle,  the  coronal  suture,  the  fore- 
head, nose,  mouth,  and  chin. 

Lastly,  the  head,  placed  in  the  right  posterior  occipito-iliac  position,  may, 
when  once  down  in  the  excavation,  depart  from  the  chest,  and  the  vertex 
presentation  be  thus  spontaneously  converted  into  one  of  the  face,  at  the 
inferior  strait ;  Ave  witnessed  a  case  of  this  kind  at  the  Clinique  in  1838. 

This  transmutation  takes  place,  says  M.  Guillemot,  in  the  following 
manner :  the  occiput  being  arrested  by  some  point  on  the  posterior  part  of 
the  excavation,  instead  of  advancing  along  the  perineum  towards  the  inferior 
strait,  ascends  in  the  curvature  of  the  sacrum  by  executing  the  movement 
of  rotation  backwards,  and  being  at  the  same  time  thrown  back  upon  the 
posterior  part  of  the  chest.  While  this  is  going  on,  the  forehead  and  face 
descend  behind  the  pubis  and  pass  downwards  and  backwards,  until  the 
chin  engages  under  the  arch,  and  then  the  head,  which  is  completely  turned 
back,  traverses  the  perineal  strait,  as  in  a  face  presentation. 

The  disposition  which  the  inclined  plane  of  the  cervix  uteri  impresses  on 
the  vertex  in  this  position,  continues  M.  Guillemot,  is  a,  frequent  cause  of  a 
similar  transmutation  above  the  abdominal  strait.  The  slight  backward 
inclination  of  the  head,  which  always  exists  in  these  positions,  may  correct 
itself  when  the  uterine  contractions,  by  acting  on  the  foetus,  keep  the  chin 
applied  to  the  neck  ;  but,  on  the  other  hand,  the  reversion  may  be  carried 
still  further,  or  be  entirely  completed,  if  any  obstacle  impedes  the  descent 
of  the  occiput  into  the  excavation ;  finally,  in  cases  of  uterine  obliquity, 
where  the  inclination  of  the  vertex  is  greater,  the  backward  tendency, 
instead  of  disappearing,  would  be  increased,  and  the  occiput  would  then 
ascend  and  ihe  forehead  descend. 


326  LABOR. 

Like  the  author  quoted,  I  admit  the  fact,  though  I  think  it  rare;  but  1 
cannot  acknowledge,  like  him,  the  truth  of  the  following  proposition,  i.  e. 
that  if  the  conditions  of  transmutation  which  then  exist  may  he  appreciated 
by  a  comparison  of  the  face  labors  with  those  of  the  occipito-posterior  posi- 
tions, we  should  not  depart  far  from  the  truth  (I believe  it  would  be  a  wide 
departure*)  by  announcing  that,  in  every  three  occipito-posterior  positions, 
one  of  them  would  give  rise  to  a  face  presentation. 

Lastly,  whatever  may  be  the  mode  of  the  delivery  of  the  head  in  the  right 
posterior  occipito-iliac  position,  the  occiput  always  inclines  towards  the 
internal  surface  of  the  right  thigh,  and  the  face  is  directed  to  the  left  one ; 
this  external  movement  (restitution)  results  from  the  internal  rotation  of  the 
shoulders,  in  consequence  of  which  the  left  shoulder,  which  was  originally 
the  anterior,  gets  under  the  arch  of  the  pubis,  and  the  right  one  into  the 
hollow  of  the  sacrum,  and  then  the  shoulders  and  the  remaining  part  of  the 
trunk  are  expelled  in  the  manner  already  stated. 

Observations  relative  to  the  Mechanism  of  Delivery  in  Vertex  Presentation . — 
The  great  care  we  have  taken  in  describing  the  natural  labor  in  these  two 
varieties  of  the  two  fundamental  positions,  will  absolve  us  from  repeating  it 
anew  in  the  other  varieties. 

In  fact,  the  left  transverse  occipito-iliac  position  does  not  differ  from  the 
anterior  one ;  unless,  perhaps,  the  movement  of  rotation,  which  brings  the 
occiput  in  front,  is  somewhat  more  extended  ;  and  what  we  have  stated  con- 
cerning the  two  modes  of  termination  in  the  right  posterior  occipito-iliac 
position  applies  equally  well  to  the  left  posterior  one;  but  we  must  add  that 
the  movements  of  rotation  will  then  take  place  from  left  to  right,  since  the 
occiput  is  primitively  turned  towards  the  left  side. 

Lastly,  in  the  other  two  varieties,  the  right  anterior  and  the  right  trans- 
verse occipito-iliac  ones,  the  mechanism  is  still  the  same  as  in  the  corre- 
sponding varieties  of  the  left  occipito-lateral  position,  the  occiput,  however, 
turning  from  right  to  left  so  that  the  rotation  occurs  toward  the  right  thigh. 

From  the  foregoing,  the  reader  will  see  that,  in  order  to  study  the 
mechanism  of  labor  in  the  vertex  positions,  we  have  been  obliged  to  con- 
sider each  of  the  periods,  or  stages,  composing  it  separately.  Thus,  we  first 
examined  the  movement  of  flexion,  then  of  descent,  next  the  internal  rota- 
tion, the  extension,  and  the  external  rotation  ;  but  it  must  not  be  supposed 
that  these  different  movements  occur  successively,  one  after  the  other,  in 
the  order  just  described. 

1.  The  forced  flexion  spoken  of  as  happening  before  the  descent,  frequently 
only  takes  place  simultaneously  with  the  latter.  Often,  indeed,  the  head  is 
not*  flexed  until  the  descent  is  completed,  and  it  encounters  the  resistance 
from  the  floor  of  the  pelvis  ;  and  then  only,  in  the  majority  of  cases,  is  the 
flexion  carried  to  its  highest  degree.  We  can  imagine  that  this  would 
nearly  always  be  the  case,  since  the  head  is  engaged  in  the  excavation  in 
most  women  long  before  the  commencement  of  labor;  and  even  in  those 
cases  where  it  is  still  above  the  superior  strait  at  the  time  of  the  membranes 
being  ruptured,  the  presenting  diameters  will  allow  it  to  traverse  the  upper 
oart  of  the  excavation  without  meeting  any  marked  resistance. 

The  movement  of  flexion  likewise  presents  some  irregularities  :  for  instance. 


MECHANICAL   PHENOMENA    OF    LABOR. 


327 


it  is  not  at  all  unusual,  more  especially  in  the  occipito-posterior  positions, 
lor  the  chin,  instead  of  approaching  the  chest,  to  depart  from  it ;  and,  con- 
sequently, for  the  head  to  become  more  extended,  and  the  anterior  fonta- 
nels gradually  so  get  towards  the  centre  of  the  excavation.  However,  this 
anomaly  is  usually  temporary,  for  the  head  is  flexed  anew  when  it  reaches 
the  pelvic  floor.  . 

In  some  rare  cases,  the  opposite  of  the  preceding,  the  posterior  fontanel  le 
occupies  the  centre  of  the  excavation,  either  because  the  flexion  has  gone 
beyond  its  usual  limits,  or  else,  because  the  trunk  is  inclined  backwards  ; 
but  here,  also,  the  resistance  from  the  perineum  gradually  brings  back  the 
head  to  its  regular  situation.     (P.  Dubois.) 

2.  The  rotation  sometimes  commences  prior  to  the  arrival  of  the  head  at 
the  inferior  strait,  and  before  the  descent  is  completed.  So  that,  in  such 
cases,  the  three  first  stages  of  the  labor  occur  at  the  same  time ;  thus  the 
head  is  flexed,  descends,  and  rotates  all  at  once. 

Some  curious  varieties  of  rotation  are  occasionally  met  with,  which  should 
be  known  to  the  student.  For  instance,  it  may  be  incomplete,  the  head 
still  retaining  a  great  obliquity  pending  the  whole  duration  of  its  disengage- 
ment ;  or  it  may  not  take  place  at  all,  which  happens,  as  we  have  already 
seen  in  certain  occipito-posterior  positions,  or  it  may  also  occur  in  the 
transverse  ones.  In  this  latter  variety,  which  is  the  rarest  of  all,  the  occiput 
and  the  forehead  disengage  alongside  of  the  internal  surface  of  the  ischiatic 
tuberosities ;  the  occiput  escapes  first,  and  then  the  forehead  by  a  movement 
of  extension  analogous  to  the  ordinary  mechanism.  Madame  Lachapelle 
reports  having  observed  three  cases  of  this  kind.  In  some  exceptional 
instances,  the  rotation  exceeds  the  ordinary  limits  :  thus,  for  example,  if  the 
occiput  is  placed  in  relation  with  the  right  sacro-iliac  symphysis  at  the 
beginning  of  the  labor,  it  may  successively  correspond  with  the  right  extre- 
mity of  the  transverse  diameter,  the  posterior  face  of  the  right  acetabulum, 
the  symphysis  pubis,  and  the  left  cotyloid  cavity;  and  then,  after  a  moment 
of  repose,  it  retrogrades  and  places  itself  once  more  behind  the  symphysis. 
M.  P.  Dubois  originally  pointed  out  this  fact,  and  I  have  twice  since  had 
an  opportunity  of  verifying  its  truth. 

Again,  the  rotation,  by  which  the  occiput  is  brought  in  front,  sometimes 
only'takes  place  just  as  the  head  is  overcoming  the  final  resistances  from 
the  soft  parts;  on  one  occasion,  I  observed  and  pointed  out  this  fact,  in  a 
primiparous  woman,  to  all  the  students  then  present  at  the  Clinique ;  the 
child's  head  was  in  the  right  posterior  occipito-iliac  position,  and  it  had 
descended  to  the  pelvic  floor  and  had  cleared  the  interior  strait  without 
rotation  taking  place ;  the  perineum  was  forcibly  distended,  the  vulva  widely 
dilated,  the  parietal  protuberances  were  engaged,  and  the  occiput  had  but 
a  few  lines  to  pass  over  in  order  to  escape  at  the  anterior  perineal  commis- 
sure ;  when,  under  the  influence  of  a  new  pain,  the  head  rotated  briskly, 
the  o'eciput  gained  the  front,  the  forehead  simultaneously  rolling  into  the 
perineal  concavitv,  and  the  labor  terminated  almost  immediately. 

The  rotation  within  the  excavation  is  certainly  one  of  the  most  curious 
movements  executed  by  the  fetal  head  during  the  whole  process  of  a  natural 
labor-  indeed,  from  what  we  have  hitherto  stated,  it  must  be  evident  that. 


328  LABOR. 

whatever  be  the  primitive  relations  of  the  occiput  with  the  various  points 
of  the  circumference  of  the  superior  strait,  it  finally  succeeds  in  getting 
under  the  symphysis  pubis.1  Now,  the  physical  cause  of  this  movemeiit  is 
nowhere  given  in  the  writings  that  have  been  published  on  the  subject  prior 
to  M.  P.  Dubois,  who  has  paid  particular  attention  to  this  point,  and  who, 
after  refuting  the  influence  of  the  inclined  planes,  advanced  by  the  older 
accoucheurs,  as  the  cause  of  the  movement,  adds,  "This  cause  evidently 
resides  in  the  combination  of  a  great  number  of  elements,  viz.,  on  one  hand, 
the  size,  form,  and  mobility  of  the  parts  which  are  expelled,  and,  on  the 
other,  the  capacity,  the  shape,  and  the  resistance  of  the  canal  traversed  by 
them  ;  and  such  is  the  influence  of  this  association,  that  the  foetal  parts 
place  themselves  in  the  most  favorable  conditions  for  delivery ;  thus,  if  an 
active  resistance  is  made  to  them  at  one  point,  they  withdraw  from  that,  and 
seek  another  where  there  is  more  space  and  liberty.  The  mobility  of  the 
traversing  parts,  and  the  extreme  lubricity  of  those  which  are  traversed, 
render  all  this  very  simple  and  intelligible.  In  fact,  every  accoucheur  must 
have  remarked  that,  in  those  instances  where  the  sacro-pubic  diameter  is 
contracted,  the  foetal  head,  if  oblique  before  the  labor,  constantly  places 
itself  then  in  a  transverse  direction,  that  is,  in  the  one  offering  the  least 
possible  dimension  to  the  shortened  diameter;  and  this  fact  is  nothing  else 
than  a  very  simple  effect  of  those  same  causes,  of  which  the  rotation,  when 
extensive,  is  a  very  complicated  consequence."  (Journal  des  Connaissance? 
Medico-  Ch  irurgicales.) 

M.  P.  Dubois  further  relates  the  following  experiment  in  support  of  his 
explanation  of  the  process  of  rotation  :  "  The  flaccid  and  voluminous  uterus 
of  a  woman,  who  died  soon  after  delivery,  was  freely  opened  near  the  os 
uteri,  and  her  foetus  was  placed  in  it  near  the  soft,  gaping  orifice,  in  the 
right  posterior  occipito-iliac  position  of  the  vertex ;  then  several  midwife 
students,  by  pushing  the  child  from  above  downwards,  caused  it  to  enter 
the  excavation  without  difficulty  ;  but  it  required  a  much  greater  effort  to 
make  the  head  traverse  the  perineum  and  clear  the  vulva ;  and  it  was  not 
without  some  surprise  that  we  noticed,  in  three  different  trials,  that,  as  soon 
as  the  head  passed  the  external  genital  parts,  the  occiput  was  in  front  and 
to  the  right,  while  the  face  turned  backwards  and  to  the  left.  Again,  we 
repeated  the  experiment  a  fourth  time  ;  but  now  the  head  passed  the  vulva, 
with  the  occiput  remaining  posteriorly.  We  then  took  a  still-born  child, 
delivered  the  preceding  day,  which  was  much  larger  than  the  other,  and 
placed  it  in  the  same  conditions  as  the  first,  and  on  two  successive  trials  the 
head  cleared  the  vulva  after  having  performed  the  rotation  ;  on  the  third 
«ind  succeeding  essays  it  was  disengaged  without  executing  this  movement : 
that  is,  the  process  of  rotation  continued  until  the  perineum  and  vulva  had 

1  M.  Naegele  has  only  known  the  occiput  to  disengage  posteriorly  seventeen  times 
»ut  of  twelve  hundred  and  forty-four  occipito-posterior  positions;  and  even  in  those 
ca°es  it  was  always  possible  to  appreciate  the  exceptional  circumstances  that  had 
favored  this  irregularity:  such  as,  an  amplitude  of  the  pelvis,  or  numerous  former 
labors,  lacerations  of  the  perineum,  or  the  softness,  flexibility,  rednaibility,  and  want 
of  consistence  of  the  head,  or  an  extreme  smalluess  of  the  child,  the  presence  of 
•wins,  4c,  <vc. 


MECHANICAL   PHENOMENA    OF   LABOR.  329 

lost  Lie  power  of  resistance  that  produced  it,  or  which,  at  least,  had  deter- 
mined its  accomplishment."     (Loc.  cit.) 

I  do  not  know  whether  the  explanations  and  experiments  of  M.  P.  Dubois 
will  render  the  cause  of  rotation  very  simple  and  intelligible  to  every  reader  ; 
but,  as  to  myself,  I  am  constrained  to  admit  that  they  describe  and  confirm 
the  fact,  but  that  they  do  not  explain  it.  True,  there  can  be  no  doubt  that 
the  cause  of  rotation  is  to  be  sought  for  in  the  form  and  direction  of  the 
canal,  and  in  the  shape  and  size  of  the  fcetal  head;  but  let  us  see  if  it  would 
not  be  possible  to  ascertain  the  influence  of  those  divers  circumstances  more 
precisely. 

The  uterus  is  situated  very  nearly  in  the  axis  of  the  superior  strait,  and 
therefore  the  sum  of  its  expulsive  forces,  or,  to  speak  more  clearly,  the  sum 
of  the  contractions,  may  be  represented  as  operating  according  to  the  direc- 
tion of  its  axis.  Now,  supposing  the  head  to  be  in  the  right  posterior  occi- 
pito-iliac  position,  the  occiput,  urged  on  by  the  uterine  contraction  transmitted 
by  the  spine,  will  descend  in  the  line  of  its  axis :  that  is,  from  above  down- 
wards, and  from  before  backwards  ;  and  it  will  continue  on  until  it  is 
arrested  by  the  resistance  from  the  inferior  and  lateral  parts  of  the  pelvis, 
or  from  the  soft  parts  constituting  the  floor  of  the  perineum.  There  it  is 
arrested,  provided  the  resistance  be  considerable,  and  thenceforth  the  occi- 
put must  necessarily  change  its  direction.  In  fact,  the  resistance  may  be 
represented  by  a  force  operating  in  a  direction  perpendicular  to  the  surface 
whereon  the  head  strikes,  and  which  is  applied  to  the  foetal  cranium  at  its 
point  of  contact  with  the  posterior  plane  of  the  excavation.  This  point  of 
contact,  in  the  case  before  us,  is  evidently  the  right  lateral  and  posterior 
part  of  the  head,  which  strikes  against  some  point  in  the  hinder  wall  of  the 
excavation  ;  the  child's  head,  or  rather  the  occipital  extremity  of  it,  is  from 
that  time  subjected  to  two  different  forces,  one  of  which  acts  from  above 
downwards,  before  backwards,  and  slightly  from  left  to  right  (this  is  the 
uterine  contraction)  ;  and  the  other  from  behind  forwards,  and  a  little  from 
below  upwards  (this  is  the  resistance,  or  force,  represented  by  the  perpendi- 
cular to  the  surface  impinged  upon  by  the  head).  By  representing  this 
force  derived  from  the  resistance,  and  that  from  the  uterus  communicated 
through  the  spine  in  the  line  of  axis  of  the  superior  strait  by  a  parallelo- 
gram, we  obtain  a  diagonal  or  resultant  from  these  two  forces  that  points 
out  the  direction  of  the  movement  that  is  to  take  place.  Now,  by  con- 
structing such  a  parallelogram,  we  observe  that  the  occiput  must  evidently 
pass  forwards,  downwards,  and  to  the  right;  since  the  diagonal  or  resultant 
of  the  forces  is  directed  from  behind  forwards,  from  above  downwards,  and 
from  left  to  right.1 

The  extent  of  this  downward  progress,  and  the  rapidity  of  its  execution, 
are  always  proportionate  to  the  energy  and  duration  of  the  contraction, 
and  to  the  resistance  offered  by  the  pelvic  floor.     This  also  explains  why 

1  In  an  article  published  in  184G,  two  years  after  the  appearance  of  my  first  two 
editions,  Prof.  Simpson  advanced  nearly  the  same  theory,  adding  that  no  one  had 
before  given  a  satisfactory  explanation  of  this  movement  of  rotation.  Though  glad 
to  find  my  theory  confirmed  by  that  of  the  learned  Edinburgh  Professor,  I  am  sorrv 
to  hrve  to  reirind  him  that  my  first  edition  was  published  in  1840. 


330  LABOR. 

the  rotation,  after  being  a  long  time  delayed,  is  sometimes  suddenly  and 
completely  effected  during  a  violent  pain  ;  as  also  why,  under  other  circum- 
stances, and  more  particularly  in  those  instances  where  the  pains  are  feeble 
or  short,  this  movement  only  takes  place  gradually,  and  requires  for  its 
entire  completion  a  much  longer  period  and  more  numerous  contractions.1 

Lastly,  this  theory  enables  us  to  explain  those  differences  noticed  in  the 
rotation  according  to  the  part  of  the  excavation  where  it  commences;  thus, 
it  has  been  stated  that  usually  the  process  only  begins  when  the  child's 
head  reaches  the  pelvic  floor ;  indeed,  this  could  hardly  be  otherwise,  since 
until  that  period  the  head,  from  being  strongly  flexed,  and  offering  i1s 
smallest  diameters  to  those  of  the  strait,  had  encountered  no  resistance 
whatever  from  the  osseous  portion  of  the  pelvic  canal ;  but  we  can  readily 
imagine  that  if  the  head  be  voluminous,  the  pelvis  rather  small,  the  supe- 
rior strait  too  much  inclined,  or  the  uterus  too  oblique,  the  resistances 
might  be  felt  much  sooner,  and  the  occiput  hardly  have  entered  the  exca- 
vation, before  it  would  strike  against  the  posterior  wall  and  be  compelled 
to  follow  the  new  direction  impressed  upon  it  by  the  resultant  (diagonal) 
of  the  forces. 

This  explanation  accounts  readily  for  the  absence  of  rotation,  and  the 
disengagement  of  the  head  in  the  posterior  position.  What,  according  to 
M.  Naegele,  are  the  kinds  of  cases  in  which  this  exception  has  been  observed? 
We  have  already  stated  them :  they  are  those  in  which  the  large  size  of  the 
pelvis,  the  slight  resistance  of  the  soft  parts,  occasioned  by  previous  labors 
or  ruptures  of  the  perineum,  or  else  the  small  size  of  the  foetus,  or  the  re- 
ductibility of  its  head,  permit  its  passage  through  the  canal  without  en- 
countering resistance,  and,  consequently,  without  any  alteration  of  the  first 
direction  of  the  uterine  force  by  a  new  one. 

3.  The  trunk  participates,  as  we  have  elsewhere  stated,  in  the  rotation 
of  the  head  ;  this,  however,  may  not  occur ;  at  least  two  cases  reported  by 
M.  P.  Dubois  would  seem  to  prove  as  much. 

4.  The  rotation  of  the  shoulders  after  the  head  is  delivered  may  also  pre- 
sent two  opposite  conditions ;  that  is,  it  may  either  take  place  in  a  partial 
manner  or  else  not  at  all,  the  shoulders  then  disengaging  transversely.  This 
last  circumstance  is  not  very  unusual,  and,  in  my  opinion,  clearly  tends  to 
confirm  the  views  of  M.  Gerdy  on  the  process  of  rotation ;  for  when  it  does 
not  occur,  the  head  undergoes  no  rotation.  But  the  latter  should  always 
execute  this  movement,  however  great  the  immobility  of  the  shoulders,  if 
the  process  is  a  consequence,  as  Baudelocque  supposed,  of  the  untwisting  of 
the  neck. 

lThia  movement  takes  place  gradually,  says  M.  Ntegele,  in  a  slow  spiral  direction  : 
for  if  the  vaginal  touch  be  resorted  to  during  the  pain,  the  small  fontanelle,  which  was 
originally  directed  to  the  right  and  posteriorly,  will  then  be  found  to  place  itself  alto- 
gether to  the  right,  towards  the  descending  branch  of  the  ischium  :  but,  in  proportion 
as  the  paih  diminishes,  it  returns  step  by  step  to  the  place  it  occupied  before.  Again, 
if  the  finger  be  kept  in  contact  with  the  head,  the  posterior  fontanelle,  which  in  the 
absence  of  a  pain  is  wholly  to  the  right,  will  be  observed,  during  the  latter,  to  turn 
forwards  towards  the  obturator  foramen,  from  whence  it  again  departs  as  the  pain 
goes  off;  and  it  keeps  up  these  alternate  movements  for  some  time,  unt;»  finally  it 
Di tomes  fixed  opposite  this  foramen. 


MECHAIS/CAL     PHENOMENA    OF    LABOR.  331 

Sometimes,  on  the  contrary,  the  same  movement  that  rendered  the  shoul- 
ders transverse  before  the  delivery  of  the  head  continues  after  the  expulsion 
of  this  latter  in  such  a  way,  that  the  shoulder  which  was  originally  anterior, 
instead  of  retrograding  towards  the  pubic  arch  passes  behind,  while  tho 
other  that  was  primitively  posterior  gains  the  apex  of  this  arch,  and  the 
face  then  turns  towards  the  internal  surface  of  the  right  thigh  in  the  right 
occipito-iliac,  and  to  the  left  thigh  in  the  left  occipito-iliac  positions. 

§  4.  Inclined,  or  Irregular  Vertex  Presentations. 

Under  the  name  of  inclined,  or  irregular  presentations  of  the  vertex,  we 
have  designated  those  (page  311)  in  which  the  sagittal  suture,  instead  of 
being  placed  very  nearly  in  the  axis  of  the  superior  strait,  looks  either  to 
the  fore  or  hinder  part  of  the  pelvis,  as  well  as  those  in  which  the  forehead 
or  the  occiput  is  placed  at  the  centre  of  the  strait,  in  consequence  of  the 
incomplete  or  exaggerated  flexion  of  the  head.  Baudelocque  and  his  school 
have  considered  these  as  so  many  distinct  presentations,  which  they  have 
accordingly  denominated  the  presentations  of  the  side  of  the  head,  or  ear. 
forehead,  and  occiput ;  but  we  shall  follow  the  example  of  Lachapelle, 
Nsegele,  Stoltz,  and  P.  Dubois,  by  including  them  all  in  the  general  term 
of  vertex  presentations.  In  fact,  they  scarcely  ever  impede  the  course  of 
the  labor,  and  seldom  modify  its  mechanism. 

For  example,  let  us  take  the  first  position  (the  left  anterior  occipito-iliac), 
and  suppose  it  to  be  inclined  on  its  anterior  (right)  parietal  region ;  then 
the  right  parietal  protuberance  corresponds  to  the  centre  of  the  strait,  and 
the  sagittal  suture  looks  towards  the  first  bone  of  the  sacrum.  When  the 
contractions  take  place,  the  head  will  descend  just  as  in  a  natural  position, 
excepting  that,  upon  its  entrance  into  the  excavation,  or  during  the  first 
half  of  the  descent,  it  will  undergo  a  movement  of  correction,  in  conse- 
quence of  which  the  posterior  parietal  protuberance  will  describe  an  arc  of 
a  circle  around  the  anterior  one  as  a  centre,  and  both  will  soon  appear  on 
the  same  plane,  and  the  labor  terminate  as  usual.  Of  course,  this  process 
of  correction  would  operate  in  the  opposite  direction  if  the  inclination  were 
on  the  posterior  parietal  region  instead  of  the  anterior ;  however,  the  recti 
fication  is  then  much  more  difficult,  owing  to  the  direction  of  the  expulsive 
force,  which  has  a  continual  tendency  to  augment  the  inclination. 

In  those  cases  where  the  flexion  of  the  head  is  incomplete,  as  in  the  fore- 
head presentations  of  Baudelocque,  it  will  become  perfected  during  the 
descent,  and  the  same  will  occur  when  it  is  exaggerated  (the  presentation 
of  the  occiput  of  Baudelocque) ;  the  forehead  becoming  lower  and  lower. 

§  5.  Prognosis. 

The  vertex  presentations  are  the  most  favorable  of  all,  and  this  statement 
will  be  more  fully  verified  when  we  study  the  prognosis  of  the  other  pre 
sentations. 

But  the  vertex  positions  are  not  all  equally  advantageous ;  and  we  may 
lay  it  down  as  a  general  proposition  that  those  in  which  the  occiput  is 
turned  towards  some  point  of  the  anterior  half  of  the  pelvis,  at  the  begin- 
ning of  the  labor,  are  more  favorable  than  those  in  which  it  looks  pos- 
teriorly. 


332  LABOR. 

In  occipito-posterkr  positions,  the  head,  in  the  early  part  of  the  labor, 
generally  remains  quite  high  and  less  flexed  than  -when  the  occiput  is  in 
front,  a  fact  shown  by  the  difficulty  then  experienced  in  reaching  the  pos- 
terior fontanelle.  The  descent,  also,  is  very  slow,  and  barely  complete  until 
rotation  has  brought  the  occiput  in  front. 

In  the  latter  case,  as  hitherto  demonstrated,  the  labor  may  terminate  by 
two  varieties  of  mechanism  which  are  altogether  different  from  each  other: 
that  is,  the  occiput  either  comes  in  front,  so  as  to  get  behind  the  symphysis 
pubis,  or  else  it  remains  posteriorly  throughout  the  labor. 

Whenever  the  posterior  position  converts  itself  into  an  occipito-pubic  one, 
the  very  considerable  extent  of  the  rotation  then  demands  a  rather  more 
energetic  contraction  on  the  part  of  the  womb  than  where  the  occiput  was 
originally  nearer  to  the  anterior  arch  of  the  pelvis,  and  the  labor  is,  there- 
fore,  somewhat  more  painful,  though  in  general  it  is  not  serious. 

But  the  expulsion  becomes  particularly  difficult  when  the  head  main 
tains  its  primitive  position,  and  does  not  rotate,  as  we  shall  endeavor  to 
prove  ;  though  first,  let  us  establish  as  an  axiom,  the  evidence  of  which  no 
one  can  deny,  that  whenever  a  straight  and  an  inflexible  trunk  has  to  pass 
through  a  curved  canal,  it  will  do  so  the  more  readily  as  the  canal  is  shorter 
and  less  curved,  or  the  trunk  itself  is  the  more  diminutive. 

Now,  in  the  folded  condition  exhibited  by  the  child's  body  in  vertex  pre- 
sentations, the  trunk,  which  represents  the  great  longitudinal  axis,  may  be 
divided  into  two  portions;  one  of  which,  constituted  by  the  spine  and  the 
inferior  extremities,  is  flexible,  and  can  accommodate  itself  to  the  pelvic 
curvature,  and,  therefore,  its  expulsion  should  offer  no  difficulty;  while  the 
other,  corresponding  to  all  the  space  between  the  vertex  and  the  atloido- 
axoid  articulation,  forms  a  straight,  inflexible  stem.  Now,  it  is  evident 
that  in  the  primitive  occipito-anterior  positions,  or  in  the  posterior  ones, 
which  afterwards  become  converted  into  anterior,  that  portion  of  the  straight 
inflexible  stem  which  the  long  axis  of  the  foetus  represents,  is  reduced  to  its 
smallest  possible  dimensions,  and  it  only  has  to  traverse  the  shortest  and 
least  curved  part  of  the  canal,  I  mean  the  symphysis  pubis ;  whence  one 
extremity  is  clear  at  the  inferior,  while  the  other  is  scarcely  engaged  at  the 
superior  strait.  But  does  the  same  thing  occur  in  those  occipito-posterior 
positions  that  remain  posterior  until  the  end  of  the  labor? 

"We  know  the  occiput,  in  this  latter  case,  is  the  first  to  escape  at  the 
anterior  perineal  commissure,  and  it  therefore  has  to  traverse  all  the  front 
surface  of  the  sacrum  and  of  the  greatly  distended  perineum.  But  as  the 
child's  neck  is  not  long  enough  to  thus  measure  the  whole  posterior  wall  of 
the  pelvic  canal,  the  chest  must  engage  in  the  excavation  soon  after  the 
head,  and  the  latter,  as  a  necessary  consequence,  must  be  forcibly  flexed  on 
the  breast.  Owing  to  this  forced  flexion,  the  straight  inflexible  stem  extends 
not.  only  from  the  vertex  to  the  atloido-axoid  articulation,  but  even  to  the 
first  dorsal  vertebra,  and  it  is,  therefore,  much  longer  than  usual ;  yet  more, 
it  has  to  traverse  the  whole  anterior  face  of  the  sacrum  prolonged  by  the 
perineum,  that  is  to  say,  the  longest  and  the  most  curved  part  of  the  pelvic 
walls. 

When  c  it  is  evident  that  the  expulsion  of  the  foetus  in  this  case  must  bti 


MECHANICAL    PHENOMENA    OF    LABOR. 


333 


much  more  tedious  and  painful  than  in  the  others;  however,  we  cannot 
admit  that  the  delivery  is  absolutely  impossible.  M.  Capuron,  who  still 
professes  this  latter  belief,  supposes  (the  occiput  remaining  posteriorly)  that 
the  labor  can  only  take  place  when  the  foetal  head  is  unusually  small,  or 
the  pelvis  very  large;  but  this  opinion  is  opposed  at  the  present  day  by  too 
great  a  number  of  facts,  to  require  us  to  refute  the  theoretical  proofs  upon 
which  he  relies. 

There  is  yet  another  reason  for  the  occipito-posterior  positions  being  more 
difficult  than  the  anterior  ones ;  a  reason  to  which  sufficient  importance  has 
not,  in  my  estimation,  been  attached:  I  allude  to  the  mode  in  which  the 
uterine  contractions  are  transmitted.  Observe,  in  fact,  when  the  occiput  is 
in  front,  that  these  are  communicated  to  it  by  the  spine,  nearly  in  a  direct 
line,  whilst  they  only  reach  it  when  this  part  is  posterior  at  the  close  of 
labor,  by  describing  a  well-marked  curve,  owing  to  the  extreme  flexion  of 
the  head  on  the  chest. 

Hence,  there  would  be,  as  every  one  knows,  a  great  loss  of  force ;  and 
observe  further,  that  such  loss  coincides  precisely  with  an  occipito-posterior 
position,  which,  for  the  reasons  before  stated,  occasions,  of  itself,  still  greater 
difficulties  in  the  delivery. 

Now,  to  have  demonstrated  that  the  labor  is  longer  and  more  difficult  in 
those  cases  in  which  the  occiput  remains  posteriorly,  is,  in  effect,  to  prove 
that  it  was  at  the  same  time  more  dangerous  both  to  the  mother  and  child. 
In  fact,  it  is  in  such  instances  especially  that  a  rupture  of  the  perineum 
is  to  be  feared;  it  being  very  difficult  indeed  to  prevent  such  an  accident; 
it  is  then,  also,  those  central  lacerations  of  the  perineum  are  apt  to  take 
place,  in  which  the  posterior  commissure  of  the  vulva  and  the  sphincter  ani 
remain  intact,  while  the  foetus  forces  a  way  for  itself  through  the  distended 
perineum. 

Such,  indeed,  is  the  effect  of  the  length  of  the  straight  stem  represented 
by  the  foetus,  and  of  the  length  of  the  curve  represented  by  the  canal,  that 
in  order  to  accomplish  expulsion  it  becomes  necessary  either:  1.  That 
the  straight  stem  should  break,  or  bend,  so  as  to  accommodate  itself  to  the 
curvature  of  the  canal,  which  is  impossible;  2.  That  the  curved  canal 
should  be  straightened  out ;  3.  That  the  walls  of  the  canal  should  be  rup- 
tured ;  4,  or  finally,  that  the  delivery  should  become  impossible. 

Happily,  in  the  majority  of  cases,  the  soft  parts  which  form  the  continua- 
tion of  the  posterior  wall,  allow  themselves  to  be  straightened  out ;  but 
when  they  resist,  nothing  but  their  rupture  can  allow  of  a  spontaneous 
delivery,  their  considerable  thickness  affording  the  only  explanation  of  the 
rarity  of  this  accident.1 

The  head,  by  remaining  a  long  time  in  the  excavation,  compresses  the 
neighboring 'parts,  thereby  giving  rise  to  retention  of  the  urine,  to  eschars, 
and  to  urinary  or  stercoral  fist u he. 

And  apart  from  all  these  inconveniences,  it  is  well  known  that  the  labor 
cannot  be  prolonged  without  danger ;  that  the  woman  becomes  fatigued  and 
sxhausted,  and  that  the  child  remains  compressed  and  painfully  Hexed. 

i  For  an  idea  of  the  resistance  sometimes  prcsontM  by  the  perineum,  Bee  the  article 
i„  th9  fifth  part  of  the  book,  on  The  Application  of  the  Forceps  in  Occipito-postenof 
Positions. 


334  LABOR. 

It  has  always  seemed  to  me  that  in  occipito-posterior  positions,  the  left 
one  is  attended  with  much  greater  trouble  than  the  right,  the  engagemeu' 
of  the  head  being  generally  more  difficult,  and  its  rotation  much  slower. 
Quite  often,  indeed,  the  occiput  remains  behind,  preventing,  in  first  labors, 
a  spontaneous  delivery,  besides  rendering  much  more  difficult  the  applica- 
tion of  the  forceps,  which  then  becomes  necessary. 

Whenever  a  foetal  head  is  examined,  just  after  its  delivery  in  a  vertex 
position,  there  is  always  to  be  found  a  more  or  less  considerable  tumefaction 
on  some  point  of  the  vertex,  provided  the  labor  has  lasted  long  after  the 
m<  mbranes  were  ruptured;  and  the  size  of  this  tumor  bears  a  direct  pro- 
^o-tiou  to  the  more  or  less  rapid  progress  of  the  labor.  Its  seat  is  so  con- 
stant that  it  is  easy  to  determine  in  what  position  the  child  was  born  by  a 
simple  inspection.     (See  Plate  YI.) 

For  instance,  when  the  occiput  escapes  under  the  pubic  arch,  the  tumor 
is  always  located  on  the  superior  posterior  angle  of  one  of  the  parietal 
bones,  i.e.  on  the  right  parietal  in  the  left  occipito-iliac,  and  on  the  left  one 
on  the  right  occipito-iliac  positions;  and  in  those  rare  cases,  where  the  occi- 
put is  disengaged  posteriorly,  it  is  usually  situated  about  the  centre  of  the 
vertex,  often  indeed  on  the  anterior  fontanelle ;  in  a  word,  it  is  mostly 
developed  at  the  point  which  corresponded  originally  with  the  os  uteri,  and 
subsequently  with  the  void  under  the  pubic  arch.  The  mechanism  of  its 
production  is  very  easily  understood,  for  the  whole  circumference  of  the 
head  is  strongly  compressed,  leaving  only  a  single  point  corresponding  to 
the  void  in  the  pelvis  or  arch,  which  is  not  subjected  to  that  pressure,  and 
which  must,  therefore,  become  the  seat  of  a  sero-sanguinolent  infiltration, 
just  in  the  same  way  as  the  skin  does,  when,  by  the  application  of  a  cup- 
ping-glass and  the  creation  of  a  vacuum,  it  is  thereby  protected  from  the 
atmospheric  pressure  that  operates  on  every  other  part  of  the  body. 

This  tumor,  when  large,  is  the  result  of  a  slow  and  painful  labor ;  it  is 
always  single;  and  maybe  distinguished  from  the  cephalhematoma,  with 
which  it  was  for  a  long  time  confounded,  by  the  following  characters :  the 
former  (or  the  tumefaction  caused  by  labor)  is  irregularly  circumscribed, 
whilst  the  limits  of  the  latter  are  very  distinct;  in  the  former,  the  hairy 
scalp  is  of  a  well-marked  violet  color,  the  tumefaction  has  an  (edematous 
consistence,  retaining  the  impression  of  the  finger,  and  is  not  fluctuating, 
whilst  the  skin  of  the  cephalhematoma  is  colorless,  presenting  a  well-marked 
fluctuation,  occasionally  even  some  pulsations,  and  its  base  is  limited  by 
a  prominent  osseous  border;1  in  some  instances,  however,  this  border 
is  not  developed  for  several  days  after  the  commencement  of  the  dis- 
ease; but  the  pulsations  and  the  border  are  never  met  with  in  the  other 
variety. 

Lastly,  the  semi-sanguineous  oedema  of  the  cranium  in  new-born  children 
appears  immediately  after  birth,  and  disappears  in  from  twelve  to  forty- 
eight  hours ;  but  the  cephakematoma,  on  the  contrary,  though  it  may  exist 
at  the  moment  of  birth,  scarcely  ever  appears  until  some  hours  after  the 
delivery,  and  then  lasts  for  several  weeks. 

'This  border  is  not  always  present  at  the  beginning  of  the  disease,  sometimes  not 
«aking  its  appearance  until  after  several  days. 


MECHANICAL    PHENOMENA    OF    LABOR. 


335 


Dr.  Fortin  relates  that  he  was  able,  in  one  instance,  to  detect  the  presence 
of  a  cephalaematoma  as  large  as  a  pigeon's  egg,  before  the  labor  was  ter- 
minated :  and  a  similar  statement  has  been  made  by  several  authors. 

The  sanguineous  tumor  just  spoken  of  does  not  exist  when  the  fcetus  dies 
prior  to  or  during  the  labor,  and  before  the  membranes  are  ruptured  ;  the 
inferences  which  the  medical  jurist  can  draw  from  this  fact  in  cases  where 
it  is  desirable  to  fix  the  period  of  death  of  a  new-born  child,  are  clearly 
obvious. 

AKTICLE    III. 

ON  THE  PRESENTATION  OF  THE  FACE. 

It  may  happen  when  the  cephalic  extremity  presents  at  the  superior  strait, 
that  the  head  is  not  only  extended,  but  also  turned  back  towards  the  poste- 
rior plane  of  the  child,  which  situation  constitutes  a  face  presentation.  Thii 
presentation  is  very  rare ;  thus,  it  has  been  ascertained,  from  the  most  numer- 
ous statistics,  that  the  foetus  presents  by  the  face,  on  an  average,  once  in  two 
hundred  and  fifty  to  three  hundred  labors. 

We  have  admitted  two  fundamental  positions  for  this  presentation ;  in 
one  of  which,  the  chin  looked  towards  some  point  on  the  right  lateral  half 
of  the  pelvis,  the  right  mento-iliac;  and  in  the  other,  it  was  directed  to  one 
of  the  points  on  the  left  lateral  half,  the  left  mento-iliac  position ;  and  we 
may  repeat  for  the  face  what  was  said  concerning  the  vertex  presentations, 
namely,  that  there  is  no  portion  of  the  circumference  of  the  superior  strait 
with  which  the  chin  may  not  be  in  relation  at  the  commencement  of  the 
labor ;  nevertheless,  we  shall  include  all  these  shades  of  position  in  the 
three  principal  varieties  for  each  side ;  that  is,  for  each  fundamental  one, 
we  have  the  anterior,  the  transverse,  and  the  posterior  varieties. 

The  right  mento-iliac  positions  are  somewhat  more  frequent  than  the  left ; 
about  in&the  proportion  of  thirty-one  to  forty-one,  if  we  may  judge  from  the 
statements  of  Madame  Lachapelle.  The  transverse  variety  is  rather  more 
frequent  than  the  right  posterior  one,  which  has  been  considered  erroneously 
as  the  most  common. 

The  face  presentations  are  either  classed  as  primitive  or  secondary,  accord- 
ing to  whether  they  existed  before  the  commencement  of  labor,  or  were  the 
result  of  ill-directed  contractions.  In  fact,  the  latter  have  generally  been 
considered  as  the  more  frequent  of  the  two ;  but  we  shall  have  occasion  to 
show  the  value  of  this  supposition  hereafter. 

§  1.  Causes. 

The  obliquity  of  the  womb,  according  to  most  authors,  is  the  cause  of  face 
presentations,  though  all  of  them  do  not  interpret  its  influence  in  the  same 
manner.  According  to  Deventer,  if  the  womb  be  inclined  to  the  right  side, 
and  the  vertex  be  placed  in  the  left  occipito-iliac  position,  the  contractions, 
taking  place  in  the  direction  of  the  uterine  axis  after  the  membranes  are 
ruptured,  will  force  the  foetus  from  above  downwards,  and  from  right  to 
left,  so  lhat  the  vertex  will  strike  against  the  left  border  of  the  superior 
strait,  and  the  head,  being  thus  arrested,  will  be  thrown  back  upon  the 
posterior  plane  of  the  child.     Baudelocque,  though  admitting  the  right 


336  LABOR. 

uterine  obliquity,  supposes  that  a  right  occipito-ilial  position  of  the  vertex 
exists  at  the  same  time;  for,  says  he,  a  face  presentation  is  scarcely  ever 
observed,  without  the  obliquity  of  the  womb  being  on  the  side  which  corre- 
sponds to  the  occiput.  In  this  instance,  the  foetus  is  lying  on  the  right 
lateral  wall  of  the  womb  before  the  labor  sets  in,  and  the  head,  obedient  to 
its  own  specific  weight,  departs  slightly  from  the  chest ;  but  when  the  con- 
t ructions  manifest  themselves  after  the  rupture  of  the  membranes  and  the 
discharge  of  the  waters,  the  direction  of  the  forces  transmitted  to  the  head 
is  such  that,  instead  of  falling  on  the  occiput,  as  they  would  were  the  head 
flexed,  they  are  spent  on  the  forehead,  and  tend  to  force  it  down ;  but  a 
depression  of  the  latter  compels  the  occiput  to  ascend :  that  is,  causes  an 
extension  of  the  head. 

The  reader  will  perceive  that  all  these  explanations  suppose  that  the  face 
presentations  are  uniformly  the  consequence  of  deviations  from  a  vertex 
position ;  but  this,  however,  is  not  always  the  case,  for  the  face  may  often 
present  directly  at  the  superior  strait,  even  before  the  commencement  of 
the  labor  or  the  rupture  of  the  amniotic  sac.  For  instance,  Madame 
Lachapelle,  when  making  an  autopsical  examination  of  two  women  who 
died  at  full  term,  found  the  foetus  presenting  by  the  face ;  moreover,  of  the 
eighty-five  face  presentations  collected  by  the  authors  of  the  Dictionnaire 
t\i'  M&deeine,  forty-nine  had  been  clearly  made  out,  and  announced  as  such 
before  the  membranes  were  ruptured ;  and  further,  of  those  eighty-five 
women,  there  were  but  three  in  whom  the  uterus  was  in  a  state  of  well- 
marked  obliquity,  and  only  one  where  the  quantity  of  the  amniotic  liquid 
was  so  great  as  to  attract  attention.  Among  the  many  predisposing  causes 
considered  as  sufficient  to  account  for  face  presentations,  are  coiling  of  the 
cord  around  the  head  of  the  foetus,  congenital  enlargement  of  the  thyroid 
gland,  a  large  thorax — unusual  length  of  the  occiput,  resistance  to  the  occi- 
put by  the  uterine  or  pelvic  walls. 

The  reason  for  the  greater  frequency  of  the  right  mento-iliac  position 
must  evidently  be  owing,  when  secondary,  to  the  greater  frequency  of  the 
right  lateral  obliquity  that  produces  it.  There  are  several  causes,  according 
to  Madame  Lachapelle,  which  contribute  to  render  the  transverse  positions 
more  common  than  the  others :  as  1,  the  form  of  the  superior  strait  and  the 
length  of  its  diameters,  which  correspond  better  in  this  direction  with  those 
of  the  face ;  2,  the  frequency  of  oblique  or  transverse  positions,  which,  when 
the  head  falls  back,  evidently  give  rise  to  transverse  positions  of  the  face; 
3,  the  frequency  of  lateral  obliquities  of  the  uterus,  or  partial  ones  of  the 
child,  if,  as  Gardien  admits,  the  foetus  can  be  oblique  independently  of  the 
womb. 

§  2.  Diagnosis. 

[Palpation  of  the  abdomen  affords  very  little  assistance  in  the  diagnosis  of  face 
presentations.  It  will  inform  us,  indeed,  that  the  greater  axis  of  the  foetus  is  in  a 
longitudinal  direction,  and  we  may,  perhaps,  feel  the  head  to  be  in  relation  with  the 
pelvic  opening ;  but  how  can  we  know  whether  it  be  flexed  or  extended? 

The  results  of  auscultation  in  face  presentations  are  also  less  precise  than  in 
those  of  the  vertex,  so  much  so  indeed  that  M.  Dcpaul  *ays  it  were  too  much  to  ask 
that  it  should  enable  us  to  distinguish  between  them.     It  is,  however,  well  enough 


MECHANICAL    PHENOMENA    OF    LABOR.  337 

tc  bear  in  mind  M.  Devillier's  observation,  tbat  as  the  face  engages  less  easily  than 
the  vertex,  the  maximum  intensity  of  the  cardiac  pulsations  may  be  heard  at  one 
of  those  points  of  the  abdomen  where  they  are  commonly  discovered  in  vertex  pre- 
sentations with  obstruction  at  the  superior  strait.  It  may,  therefore,  lead  to  a 
mistake  of  which  it  is  well  to  be  forewarned. 

Having  determined  that  the  face  presents,  if  we  resort  to  auscultation  in  order 
to  diagnose  the  position,  the  following  facts  should  be  borne  in  mind:  When  the 
head  is  so  forcibly  thrown  back  that  the  occiput  touches  the  upper  part  of  the 
back,  the  entire  trunk  of  the  foetus  inclines  towards  its  anterior  plane,  whilst  the 
vertebral  column  has  a  strong  backward  direction.  The  sternum  of  the  child, 
therefore,  approaches  the  uterine  wall  whilst  the  back  recedes  from  it,  so  that  the 
maximum  of  the  pulsations  of  the  heart  is  no  longer  transmitted  to  the  stethoscope 
through  the  vertebral  but  through  the  sternal  region;  in  a  right  mento-iliac  posi- 
tion, therefore,  the  maximum  sounds  of  the  heart  will  be  heard  toward  the  right 
side.] 

By  the  touch  only,  can  the  diagnosis  he  made  with  certainty.  Before  the 
membranes  are  ruptured,  the  head  in  general  is  high,  and  difficult  of  access, 
so  that  it  is  almost  impossible  to  reach  the  presenting  portion,  provided  the 
membranes  are  tne  least  tense.  Again,  the  reversion  of  the  head  not  being 
yet  completed,  the  forehead  is  the  lowest  part,  and  the  one  the  finger 
encounters  in  performing  the  touch ;  whence,  by  feeling  a  hard,  rounded 
body  furrowed  by  a  membranous  interval  (the  coroual  suture),  we  might 
very  readily  mistake  it  for  a  vertex  presentation.  But  if  the  flaccid 
and  folded  membranes  can  be  depressed  without  difficulty,  or,  stilZ 
better,  if  they  have  been  recently  ruptured,  the  diagnosis  becomes  easier. 
Then  we  find  towards  one  side  of  the  pelvis  a  rounded,  solid  surface,  the 
forehead,  traversed  by  a  suture  leading  to  a  transverse  depression  ;  next  a 
triangular  elevation  whose  base,  looking  in  an  opposite  direction  from  the 
forehead,  exhibits  two  openings,  the  nares,  and  beyond  this,  a  transverse 
fissux-e  bounded  by  the  superior  and  inferior  maxillary  arches.  Sometimes, 
the  finger,  when  introduced  into  the  mouth  of  the  child,  has  been  clearly 
sensible  of  an  effort  at  suction.  On  the  sides  of  the  median  protuberance, 
two  little  soft  tumors  (the  eyes)  are  felt,  surrounded  by  an  osseous  circle ; 
and  lastly,  when  the  head  is  low  down,  an  ear  may  be  detected  behind  the 
pubis.  When  the  presentation  is  once  determined,  the  position  is  easily 
made  out,  for  the  opening  of  the  nostrils  must  evidently  look  towards  that 
part  of  the  pelvis  which  corresponds  with  the  chin.  When  a  long  time  has 
elapsed  after  the  rupture  of  the  membranes,  new  causes  of  difficulty  are  met 
with.  Thus,  the  face,  which  now  corresponds  to  the  open  space  in  the 
pelvis,  becomes  the  seat  of  a  considerable  tumefaction,  due  to  the  same 
cause  which  produces  the  tumor  of  the  scalp  in  vertex  presentations.  The 
cheeks,  being  greatly  swollen,  and  at  the  same  time  compressed  on  the  sides, 
project,  and  lie  close  to  each  other  in  front,  thus  leaving  a  deep  fissure 
between  them,  in  the  bottom  of  which  the  distinctive  characters  of  the  face 
are  entirely  concealed ;  this  fissure  might  very  readily  be  mistaken  for  the 
one  between  the  nates,  which  are  then  confounded  with  the  tumefied  cheeks. 
Further,  the  lips  are  also  swollen,  wrinkled,  and  everted,  in  such  a  manner 
as  to  offer  a  rounded  orifice  instead  of  the  usual  transverse  fissure,  and  this 
orifice  has  been  mistaken,  in  some  instances,  for  the  anus. 
22 


338 


LABOR. 


§  3.  Mechanism. 

We  shall  follow  the  example  of  Nsegele,  Dubois,  and  Lachapelle,  hy 
taking  one  of  those  varieties,  in  which  the  chin  looks  towards  one  extremity 
of  the  transverse  diameter,  as  the  type  in  our  description  of  the  mechanism 
of  natural  labor  by  the  face,  and  shall  commence  with  the  right  mento-iliae 

1.  Mechanism  of  Natural  Labor  in  the  right  Transverse  Mento-iiiac  Posi- 
tion.—  Before  the  membranes  are  ruptured,  the  head,  as  a  general  rule,  is 
but  moderately  extended,  whence  the  forehead  is  nearly  always  placed  at 
the  centre  of  the  superior  strait ;  the  chin  corresponding  to  the  right,  and 
the  bregma  to  the  left  extremity  of  the  transverse  diameter.  The  diameters 
of  the  head  hold  the  following  relations  to  those  of  the  pelvis:  the  mento- 
bregmatic  corresponds  to  the  transverse  diameter  of  the  pelvis ;  the  bi- 
temporal to  the  antero-posterior  one,  and  the  mento-bregmatic  circumference 
is  parallel  to  the  periphery  of  the  superior  strait ;  and,  therefore,  the  pelvic 
axis  traverses  the  head  in  the  direction  of  the  occipitofrontal  diameter. 

The  posterior  plane  of  the  foetus  looks  directly  to  the  mother's  left,  and 
its  anterior  plane  lo  her  right ;  its  right  side  is  in  front. 

Early  in  the  labor,  the  hag  of  waters  projects  into  the  upper  part  of  the 
excavation,  to  an  extent  proportionate  to  the  dilatation  of  the  orifice  ;  and 
its  rupture  generally  takes  place  suddenly  during  a  contraction,  with  con- 
siderable noise.  The  rupture  is  followed  by  the  escape  of  a  large  amount  of 
amniotic  fluid,  and  the  fetus  descends,  and  renders  the  diagnosis  more  easy. 

As  soon  as  the  membranes  are  ruptured,  the  mechanism  of  the  expulsion 
begins,  and  here,  as  in  the  case  of  the  vei'tex,  it  is  composed  of  six  stages  : 
i.  '.,  the  forced  extension,  the  descent,  the  rotation,  the  flexion  or  disengage- 
ment, the  external  rotation,  and  the  expulsion  of  the  body. 


FlO.  80.     Mechanism  of  face  jucoeutatiuus  (Schultze). 


MECHANICAL    PHENOMENA    OF    LABOR.  339 

a.  First  Stage.  Forced  Extension.  —  The  head  being  already  moderately 
■extended  on  the  back,  its  extension  will  be  completed  during  the  first  uterine 
contractions  that  take  place  after  the  discharge  of  the  waters,  owing  to  the 
resistance  it  will  then  meet  with.  This  forced  extension  of  the  head  changes 
but  very  little  the  relations  of  its  diameters  to  those  of  the  pelvis  (Fig.  80); 
for  instance,  the  fronto-mental  has  taken  the  place  of  the  mento-bregmatic, 
and  is  now  parallel  to  the  transverse  diameter  of  the  strait;  the  bi-temporal 
has  not  changed  at  all ;  the  facial,  or  fronto-mental  circumference  corre- 
sponds with  the  periphery  of  the  superior  strait,1  and  the  pelvic  axis  traverses 
the  head  in  the  direction  of  a  line  passing  from  the  posterior  fontanelle  to 
the  child's  upper  lip. 

B.  Second  Stage.  Descent.  —  As  soon  as  the  head  is  freely  extended,  it 
engages  in  the  excavation,  and  descends  as  far  as  the  length  of  the  neck  will 
permit.  This  last  sentence  requires  a  short  explanation.  In  the  vertex 
positions,  we  have  already  seen  that  the  head  descended  to  the  floor  of  the 
pelvis  in  such  a  way  as  to  traverse  all  the  space  between  the  superior  and 
inferior  straits,  without  changing  its  position.  But  in  the  transverse  posi- 
tion before  us,  it  is  clearly  evident  that  the  face  can  only  reach  the  pelvic 
floor  under  one  of  the  following  conditions:  that  is,  either  the  chest  will 
engage  along  with  the  head  in  the  excavation,  or  else  it  will  remain  above 
the  superior  strait ;  the  face  descending  alone  as  far  as  the  inferior  one ; 
that  is  to  say,  the  forehead  reaching  the  level  of  the  left,  and  the  chin  that 
of  the  right  tuber  ischii;  but  then  the  neck  must  necessarily  elongate  enough 
to  measure  the  whole  length  of  the  pelvis  at  its  lateral  portion,  which  is 
three  inches  and  three-quarters.  But  as  neither  of  these  two  conditions  can 
be  realized,  the  head  will  not  be  able  to  reach  the  pelvic  floor ;  and  it  is  for 
this  reason  that  we  say  the  face  only  descends  as  far  as  the  length  of  the  neck 
will  permit ;  whereby  the  descent  is  interrupted. 

C.  Third  Stage,  liotation. — The  head  then  undergoes  a  movement  of  rota- 
tion, during  which  the  chin  rolls  from  right  to  left,  so  as  to  get  behind  the 
symphysis  pubis,  while  the  forehead  rotates  from  left  to  right,  and  from 
before  backwards,  in  order  to  place  itself  in  the  concavity  of  the  sacrum. 
When  this  movement  is  effected,  the  descent  becomes  completed;  for  the 
shortness  of  the  neck,  or  the  too  great  extent  of  the  ischium,  formed  hereto- 
fore the  sole  obstacle ;  if,  therefore,  by  the  process  of  rotation,  the  neck, 
which  can  be  no  further  stretched,  is  brought  into  apposition  with  a  part 
of  the  pelvic  wall  short  enough  for  it  to  span  its  whole  length,  the  descent 
may  evidently  be  completed :  that  is,  the  breast  still  remaining  above  the 
superior  strait,  the  chin  may  descend  as  low  as  the  inferior  one,  and  thi3  is 
precisely  what  does  take  place;  for,  as  the  trunk  participates  in  the  rotation 
of  the  head,  the  neck  gets  behind  the  symphysis  pubis  at  the  same  time 
that  the  chin  reaches  the  lower  edge  of  this  symphysis,  which  is  short  enough 
to  allow  the  neck  to  subtend  its  whole  length. 

1  M.  Nsegele  further  supposes  that  the  face  is  inclined  relatively  to  the  superior 
strait,  and  that  the  anterior  cheek  is  the  most  dependent  part,  &c.  The  reasons  upoD 
which  our  objections  were  founded  to  such  an  inclination  in  the  ver.ex  presentations, 
oblige  us  also  to  reject  it  in  the  positions  of  the  face,  for  we  believe  that  the  facial 
nircuniferenc  i  is  most  usually  parallel  to  the  plane,  as  stated  in  the  text. 


340 


LABOR. 


D.  Fourth  Stage.  Flexion. — The  process  of  flexion  begins  as  soon  as  tne 
descent  is  achieved ;  indeed,  we  may  remark  that,  when  the  chin  passes 
behind  the  symphysis  pubis,  the  forehead  goes  into  the  hollow  of  the  sacrum, 
and  it  therefore  has  to  traverse,  in  order  to  arrive  at  the  inferior  strait 
simultaneously  with  the  chin,  the  whole  anterior  face  of  the  sacrum,  that 
is,  about  five  and  a  quarter  inches,  whilst  the  chin  only  descends  the  length 
of  the  symphysis,  or  one  and  a  half  inches ;  in  a  word,  this  is  found  just  in 
the  same  condition  as  the  posterior  extremity  of  the  bi-parietal  diameter  in 
vertex  presentations ;  and,  like  it,  the  forehead  has  to  describe  an  arc  of  a 
circle  around  the  chin  as  a  centre.  Now,  this  arc  cannot  be  described 
without  a  certain  degree  of  flexion  of  the  head.  Whence  it  appears  that, 
in  this  transverse  position  of  the  face,  the  descent  is  completed  at  the  same 
time  that  the  rotation  is  taking  place,  and  the  process  of  flexion  beginning. 

If  the  relations  of  the  diameters  of  the  head  to  the  inferior  strait  be  then 
examined,  we  shall  find  that  the  same  ones  are  concerned  as  at  the  begin- 
ning of  the  labor,  before  the  complete  extension  had  occurred  ;  thus,  the 
mento-bregmatic  corresponds  to  the  antero-posterior  diameter,  the  bi-tem- 
poral  to  the  transverse,  and  the  axis  of  this  strait  passes  through  the  occi- 
pitofrontal diameter :  and  thus  it  should  be ;  since,  by  the  commencement 
of  flexion,  the  head  is  replaced  in  the  state  of  semi-extension  it  had  when 
the  labor  began. 

The  chin,  under  the  influence  of  the  uterine  contractions,  next  engages 
beneath,  and  continues  passing  under  the  inferior  part  of  the  symphysis, 
until  the  fore  part  of  the  neck  comes  into  apposition  with  the  posterior  sur- 
face of  the  pubis ;  then  the  upper  part  of  the  thorax  engages  in  the  cavity, 
and  the  upper  portion  of  the  back  presses  strongly  against  the  occiput:  the 
occiput  is  depressed,  and  the  head  thereby  compelled  to  complete  its  flexion 
or  disengagement.  Of  course,  the  perineum  becomes  greatly  distended,  and 
ff-,.  si.  the  forehead,  the  bregma,  the  vertex, 

and  the  occiput,  successively  appear 
before  its  antei'ior  commissure. 

During  the  process  of  flexion,  the 
prse-trachelo-fruntal,  the  prse-tra- 
chelo-bregmatic,  and  the  prse-tra- 
chelo-occipital  diameters,  clear  in 
turn  the  antero-posterior  one  of  the 
inferior  strait. 

e.  Fifth  Stage.  Restitution. — This 
dift'ers  in  no  wise  from  the  external 
rotation  described  by  the  head  in  the 
vertex  presentations;  for  here,  also, 
it  is  a  consequence  of  the  movement 
executed  by  the  shoulders,  in  order 
to  place  themselves  in  the  direction 
of  the  antero-posterior  diameter  of 
the  strait. 

[f.  Sixth  Staffi .    Expulsion  of  Ihi  Hod;/. — This  occurs  us  in  cases  of  vertex  presentation.] 
In  addition  to  the  above,  the  mechanism  of  face  labors  sometimes  pre- 
sents a  variety,  which   we  purposely  omitted  for  fear  of  interrupting  the 


Illustrating  th<.-  position  of  the  head  when  forward 
rotation  ol  the  chin  does  not  take  place. 


MECHANICAL,    PHENOMENA    OF    LABOR.  34.1 

regular  description  ;  thus,  we  stated,  that  the  head  completed  its  extension 
and  descerded,  but  that  this  movement  of  descent  was  interrupted  by  the 
rotation  ;  *.fter  which  the  descent  was  completed,  and  at  the  same  time  the 
flexion  begun.  Now  all  the  difference  rests  on  this  last  point ;  for  in  prac- 
tice a  considerable  number  of  cases,  more  particularly  of  the  mento-poste- 
rior  positions,  are  met  with,  in  which  the  following  phenomena  are  observed: 
the  second  movement,  or  the  descent,  actually  commences,  but  is  checked 
by  the  shortness  of  the  child's  neck.  Then  a  certain  degree  of  flexion  takes 
place  before  the  rotation  occurs,  in  consequence  of  which  the  forehead  de- 
scends to  the  pelvic  floor,  and  the  mento-bregmatic  diameter  places  itself 
anew  parallel  to  the  transverse  diameter  of  the  excavation ;  then  the  pro- 
cess of  rotation  occurs,  which  carries  the  chin  behind  the  symphysis,  and 
the  labor  terminates  in  the  manner  just  indicated. 

2.  Mechanism  of  Natural  Labor  in  the  left  Transverse  Mento-iliao  Posi- 
tion.—  In  this  position,  the  expulsion  of  the  foetus  takes  place  in  absolutely 
the  same  manner  as  in  the  preceding  case.  Only  the  chin,  as  well  as  the 
anterior  plane  of  the  child,  is  to  the  left;  and  hence  the  movement  of  rota- 
tion occurs  from  left  to  right  instead  of  right  to  left,  but  all  the  rest  is  pre- 
cisely similar. 

The  same  is  also  true  of  the  two  varieties  denominated  the  right  and  the 
left  anterior  mento-iliac  positions.  The  two  other  varieties  (the  right  pos- 
terior, and  the  left  posterior  mento-sacro-iliac)  exhibit  an  identity  of 
mechanism  in  a  vast  majority  of  cases :  that  is  to  say,  the  head,  having 
reached  a  certain  depth  in  the  excavation,  then  undergoes  the  process  of 
rotation,  which  converts  the  position  into  a  mento-pubic  one  ;  indeed,  the 
necessity  for  this  movement  is  far  more  evident  here  than  in  the  mento-trans- 
verse  positions,  since  the  depth  of  the  pelvis  is  much  greater  behind  than 
on  the  sides. 

It  may,  therefore,  be  laid  down  as 'a  general,  nay,  as  an  almost  absolute 
rule,  that,  in  the  face  positions,  whatever  may  have  been  the  relations  of  the 
2hin  with  the  circumference  of  the  superior  strait  at  the  commencement  of 
the  labor,  there  must  be  a  process  of  rotation,  whereby  the  chin  is  brought 
under  the  symphysis  pubis,  before  the  labor  can  terminate  spontaneously. 
The  necessity  for  this  rotary  movement  may  be  readily  understood.  In 
order  that  delivery  may  be  accomplished  with  the  face  presenting,  it  is  abso- 
lutely necessary  that  the  chin  should  reach  the  inferior  strait ;  now,  in  the 
extended  condition  of  the  head,  the  chin  cannot  reach  this  strait,  except  the 
neck  be  capable  of  measuring  the  depth  of  that  portion  of  the  wall  of  the 
pelvis  to  which  it  corresponds.  If,  therefore,  the  symphysis  pubis  be  the 
only  part  of  the  pelvis  which  is  short  enough  to  allow  the  neck  to  measure 
its  depth,  it  becomes  indispensable  that  the  chin  should  be  turned  forward. 

In  the  numerous  varieties  of  this  position  before  admitted,  the  mechanism 
of  the  labor  only  differs  in  the  greater  or  the  less  extent  of  the  process  of 
rotation  ;  an  extent  evidently  varying  according  to  the  point  with  which  the 
chin  was  primitively  in  relation  to  the  upper  strait. 

Remarks. —  Nevertheless,  the  mechanism  of  the  face  positions  occasionally 
offers  some  anomalies,  that  require  a  more  special  notice. 

1.  Tlii'  rotation  just  described,  whose  object  is  to  bring  the  chin  constantly 


3-±2  LABOR. 

towards  the  symphysis  pubis,  and  which  has  been  spokei  of  as  absolutely 
essential  to  the  spontaneous  termination  of  the  labor,  may  not  be  executed. 
But  such  very  rare  exceptions  do  not  in  the  least  discredit  the  general  prin- 
ciple before  laid  down,  for  they  may  all  be  referred  to  those  instances  where 
the  dimensions  of  the  head  are  small  relatively  to  those  of  the  pelvis ;  or 
else  to  those  cases  in  which  the  position  of  the  face  has  been  spontaneously 
converted  into  one  of  the  vertex.  True,  Madame  Lachapelle  has  known 
the  face  to  escape  from  the  vulva  in  a  transverse  direction,  or  nearly  so,  in 
two  or  three  instances ;  but  she  carefully  adds  that  they  were  very  rare 
exceptions. 

Nowr,  to  understand  this  movement  of  rotation,  it  is  only  necessary  to 
recall  our  remarks  concerning  the  mechanism  of  labor ;  thus,  it  has  been 
shown  that  the  descent  could  not  be  completed  in  the  transverse  positions, 
until  the  chin  has  turned  towards  the  pubic  symphysis ;  and  further,  that 
when  the  head  is  extended,  the  resultant  of  the  forces  transmitted  by  the 
spine  falls  very  nearly  on  the  chin,  and  tends  to  engage  it  still  more.  Well, 
in  this  situation,  the  expulsive  force  is  either  perpendicular  or  oblique  to 
the  plane  of  the  resistance ;  if  the  former,  the  uterine  efforts  are  lost,  since 
they  do  not  contribute  in  any  wTise  to  the  progress  of  the  labor ;  but,  if  the 
force  is  oblique  to  the  resistance,  it  is  so  either  from  before  backwards,  or 
from  behind  forwards.  In  the  former  case,  it  will  have  a  tendency  to  carry 
the  chin  backwards ;  but  a  movement  of  this  kind  will  not  aid  in  the 
engagement  of  the  chin,  since  the  pelvic  wall  is  much  higher  nearer  the 
median  line ;  and  hence  the  efforts  are  still  lost. 

In  the  latter,  on  the  contrary,  the  oblique  force,  by  operating  from  behind 
forwards,  tends  to  carry  the  chin  in  front :  that  is,  towards  a  portion  of  the 
pelvic  wall,  Avhich  becomes  shorter  and  shorter  as  it  advances  anteriorly, 
and  thus  facilitates  the  descent. 

But,  after  all,  what  is  the  direction  of  the  uterine  force?  Everybody 
*nows  that  it  changes  at  each  instant ;  according  to  the  woman's  position, 
»r  the  power  of  the  contractions,  the  womb  may  be  successively  found  in  all 
three  of  the  directions  above  indicated,  relatively  to  the  resistant  plane.  If 
it  is  perpendicular  to  that  plane,  the  efforts  are  lost ;  or,  if  oblique,  from 
before  backwards,  the  contractions  are  useless  ;  they  can  only  be  fully  effica- 
cious when  acting  on  the  chin  from  above  downwards,  and  from  behind  for- 
wards. But  far  be  it  from  me  to  attribute  an  intelligent  force  to  the  uterus  ; 
for  it  is  only  by  groping  along,  so  to  speak,  that  the  womb  finally  acquires 
a  proper  direction,  though,  when  the  impulsion  is  once  given,  the  force 
becomes  more  and  more  oblique,  and  consequently  more  active.  And  it  is 
those  gropings  (excuse  the  term)  which  at  times  render  the  rotation  so  diffi- 
cult and  so  tedious. 

It  has  been  asserted,  of  late,  that  the  process  of  rotation  is  quite  as  easy 
in  the  mento-posterior  as  in  the  mento-anterior  positions.  Now,  if  I  have 
succeeded  in  making  my  views  of  the  cause  and  mechanism  of  this  move- 
ment understood,  the  reader  will  readily  comprehend  that,  in  proportion  as 
the  chin  is  turned  backward,  and  more  especially  if  towards  the  right  at 
the  same  time,  the  greater  will  be  the  difficulty  of  its  accomplishment,  since 
the  resultant  of  the  uterine  forces  becomes  nearly  perpendicular  to  the  plane 
of  resistance. 


MECHANICAL     PHENOMENA    OF    LABOR.  343 

2.  As  regarJs  those  varieties  in  which  the  chin  looks  backwards,  we  have 
already  stated  that  it  is  necessary  this  part  should  come  round  in  front, 
though  some  cases  of  mento-posterior  positions,  that  terminated  spontane- 
ously, are  found  in  the  books,  where  the  chin  did  not  get  under  the  pubic 
arch ;  writers  differ  in  their  explanations  of  this  anomaly.  M.  Velpeau  takes 
as  an  illustration  the  mento-sacral  variety,  or  the  second  position  of  Baude- 
locque,  in  which  the  chin  is  turned  toward  the  anterior  face  of  the  sacrum 
( though  we  may  observe,  in  passing,  that  this  position  is  scarcely  admis- 
sible) ;  and  he  remarks  that,  as  the  chin  does  not  rotate  in  front,  the  follow- 
ing phenomena  may  then  take  place:  the  forehead  engages  behind  the  body 
or  the  symphysis  of  the  pubis,  while  at  the  same  time  the  chin  gets 
below  the  sacro-vertebral  angle.  The  whole  head  descends  into  the  excava- 
tion beyond  the  anterior  fontanelle  for  the  anterior  plane,  and  the  face  drags 
after  it  the  front  surface  of  the  neck,  and  even  the  upper  part  of  the  chest 
behind.  The  occipito-mental  diameter,  which  still  represents  the  axis  of  the 
strait  very  nearly,  now  begins  to  perform  a  see-saw  movement  from  above 
downwards,  and  from  behind  forwards.  The  chin,  penetrating  further  and 
further  towards  the  bottom  of  the  excavation,  though  at  the  same  time 
retained  by  the  thorax,  which  cannot  advance,  forces  the  sagittal  suture  to 
slip  down  behind  the  pubis,  and  the  forehead  to  gain  the  upper  part  of  the 
inferior  strait.  The  frontal  protuberances  soon  find  a  point  of  resistance 
on  the  perineum,  and  the  posterior  fontanelle  descends  in  turn,  and  ulti- 
mately appears  at  the  summit  of  the  arch,  when  the  head  finally  escapes 
from  the  vulva  as  it  would  in  an  occipito-anterior  position  :  whence  it  fol- 
lows, adds  M.  Velpeau,  that  the  occipitofrontal  is  the  greatest  diameter  which 
can  present  at  the  planes  of  the  straits.  But  we  cannot  admit  the  truth  of 
this  last  proposition ;  for  if,  as  he  says,  the  chin  is  in  relation  with  the  ante- 
rior surface  of  the  sacrum,  and  it  descends  more  and  more,  while  the  occiput 
slips  behind  the  pubis,  it  is  evident  that  the  occipito-mental  diameter  must, 
at  a  given  moment,  traverse  the  antero-posterior  one  of  the  excavation. 
Now,  as  this  is  clearly  impossible,  we  have  to  reject  M.  Velpeau's  explana- 
tion altogether.  Besides,  the  cases  observed  by  Smellie  and  Delamotte, 
which  he  cites  in  support  of  his  theory,  prove  nothing  at  all,  for,  in  both  of 
those  instances,  the  foetuses  were  small  and  dead,  and  the  woman  had,  on  for- 
mer occasions,  been  delivered  of  voluminous  children. 

M.  Guillemot  has  explained  the  spontaneous  termination  of  the  labor  in 
these  cases  somewhat  differently ;  for  when  the  chin  does  not  rotate  in  front, 
the  labor,  according  to  his  idea,  may  terminate  in  two  ways,  namely :  1st. 
The  forehead  continues  to  descend  and  to  engage  under  the  branch  of  the 
pubis  until  the  anterior  fontanelle  appears  at  the  vulva,  which  progression 
permits  the  chin  to  advance  forward  and  reach  the  border  of  the  perineum; 
then  the  process  of  flexion  commences,  &c.  But  we  cannot  conceive  how, 
in  th  3  forced  extension  of  the  head  on  the  thorax,  it  is  possible  for  the  chin 
to  airive  at  the  anterior  perineal  commissure  by  traversing  the  whole  pos- 
terior plane  of  the  excavation,  because,  from  all  evidence,  the  breast  must 
engage  extensively  along  with  the  head,  which  is  wholly  impossible,  unless 
it  be  a  case  of  abortion. 

2d.  The  labor  by  the  face  may  be  convert* sd  into  one  by  the  vortex     and 


344  LABOR. 

this  always  takes  place,  he  continues,  in  the  following  mannei  :  the  face 
being  forcibly  pressed  on,  and  unable  to  escape  through  the  perineal  strait, 
has  a  natural  tendency  to  pass  towards  those  points  that  offer  the  least 
resistance.  Here,  this  condition  is  found  above  and  behind,  whence  the  chin 
leaves  the  perineum  and  approaches  the  foetal  chest  by  ascending  along  the 
hollow  of  the  sacrum  towards  the  sacro-vertebral  angle,  and  the  forehead 
following  this  movement  corresponds  to  the  sacrum  in  turn ;  the  vertex  is 
depressed  and  slips  behind  the  pubis,  and,  just  at  the  moment  when  the  chin 
applies  itself  to  the  child's  breast,  the  occiput  engages  under  the  pubic 
arch.  He  further  supposes  the  face  to  be  sufficiently  engaged  for  the  chin 
to  come  in  contact  with  the  perineum ;  but,  as  we  have  already  stated,  this 
is  impossible,  on  account  of  the  extent  of  the  conjoint  diameters  of  the  head 
and  breast,  both  of  which  would  be  deeply  engaged  in  the  excavation. 

But,  even  admitting  the  chin  should  descend  so  low,  where  is  the  power 
to  make  it  subsequently  rise  up  in  the  hollow  of  the  sacrum,  the  cavity  of 
which  is  occupied,  whatever  M.  Guillemot  may  say  to  the  contrary,  by  the 
deeply  engaged  breast?  For  the  uterine  contraction,  which  is  always  trans- 
mitted by  the  spine,  acts  at  first  on  the  chin  as  a  consequence  of  the  reverted 
position  of  the  head  (as  M.  Velpeau  clearly  recognized),  and  it  is  only 
because  its  power  is  inadequate  to  make  the  latter  descend  any  further,  that 
its  action  is  transferred  to  the  other  extremity  of  the  fron to-mental  diameter, 
that  is,  to  the  forehead,  which  it  then  depresses,  according  to  the  theory  of 
Guillemot.  Again,  even  supposing  that  the  chin  may  remount,  it  is  scarcely 
possible  to  believe  that  it  gets  above  the  sacro-vertebral  angle ;  it  must 
therefore  constantly  remain  in  contact  with  the  anterior  surface  of  the 
Eacrum  ;  and,  consequently,  at  a  given  moment,  the  occipito-mental  diameter 
must  traverse  the  antero-posterior  one  of  the  excavation. 

In  my  estimation,  therefore,  we  are  not  to  understand  this  as  the  true 
mode  by  which  the  mento-posterior  positions  of  the  face  are  converted  into 
occipito-pubic  ones ;  indeed,  among  all  the  cases  I  have  been  able  to  con- 
sult, I  have  only  found  three  in  which  the  chin  was  in  direct  relation  with 
the  anterior  face  of  the  sacrum,  viz.,  those  of  Smellie,  Delamotte,  and  Meza 
(reported  by  Guillemot). 

Now,  in  the  one  furnished  by  Smellie,  it  is  positively  stated  that  the  child 
was  small,  that  the  woman  had  a  large  pelvis,  and  that  she  was  usually 
delivered  very  promptly ;  Delamotte  says  nothing  about  the  head  and  the 
dimensions  of  the  pelvis,  in  his  case;  and  lastly,  Meza  was  obliged  to  apply 
the  forceps,  in  the  one  reported  by  him ;  so  of  course,  that  was  no  longer  a 
spontaneous  termination,  for  it  wrould  be  an  easy  matter  to  demonstrate  that 
the  application  of  the  forceps  may  act  in  an  altogether  different  manner 
and  even  more  advantageously,  than  the  uterine  contraction  in  this  instance : 
besides,  the  reader  will  not  forget  that,  in  the  first  two  cases,  the  children 
came  away  dead. 

All  the  other  observations  may  be  referred  either  to  the  right  or  the  left 
mento-sacro-iliac  positions ;  and,  in  these  latter,  it  appears  to  me  that  a 
spontaneous  termination  of  the  labor  might  occur  without  a  simultaneous 
engagement  of  the  chest  and  head;  for  instance,  let  us  suppose  that  the 
child  is  in  a  right  mento-sacro-iliac  position;  then,  after  the  complete  exten- 


MECHANICAL  PHENOMENA  OF  LABOR.  3-45 

sion  of  the  head,  the  face  will  descend  into  the  excavation  as  far  as  the 
length  of  the  neck  permits,  and  consequently  the  chin  will  reach  the  level 
of  the  great  sciatic  notch,  the  more  so,  as  the  form  of  this  portion  of  the 
ilium,  which  is  shaped  like  a  cone,  will  favor  the  movement  of  downward 
progression.  Having  arrived  at  this  notch,  the  chin  will  there  encounter 
soft  parts,  which  it  can  very  readily  depress,  and  this  depression  will  be 
quite  sufficient  to  augment  the  length  of  the  oblique  diameter  of  the  excava. 
tion  from  a  quarter  to  half  an  inch,  thereby  permitting  the  occipito-mentnl 
diameter  to  clear  it,  and  the  head  to  undergo  the  process  of  flexion,  thai 
will  gradually  bring  the  occiput  under  the  pubic  symphysis. 

§  4.  Inclined  or  Irregular  Face  Presentations. 

The  face  does  not  always  present  so  regularly  at  the  superior  strait,  as  to 
have  its  fronto-mental  circumference  parallel  to  the  opening  in  the  pelvis, 
since  the  same  causes  that  determine  the  inclination  in  vertex  presentations, 
may  also  render  those  of  the  face  irregular ;  and  here,  likewise,  Ave  may 
invoke  the  uterine  obliquities,  the  partial  obliquity  of  the  child,  or  an 
incomplete  or  an  exaggerated  extension  of  its  head,  to  explain  how  we 
sometimes  find  one  of  the  cheeks,  and  at  others  the  forehead  or  the  chin,  at 
the  centre  of  the  upper  strait. 

But  still,  these  are  not  to  be  considered  as  distinct  presentations,  but 
rather  as  varieties  or  shades  of  the  face  presentations,  which  scarcely  ever 
render  the  labor  more  difficult.  In  fact,  the  following  is  the  only  modifica- 
tion they  are  likely  to  cause  in  the  mechanism  of  parturition ;  in  the  malar 
positions  of  Baudelocque,  or  those  inclined  towards  the  side,  where  one 
cheek  is  at  the  centre,  the  head  undergoes  a  movement  of  correction  whilst 
engaging,  similar  to  what  it  does  in  the  parietal  inclinations  of  the  vertex, 
whereby  the  face  gradually  regains  its  normal  horizontal  direction.  In  the 
so-called  presentations  of  the  forehead  or  chin,  the  most  elevated  part 
becomes  depressed,  and  ultimately  gains  the  same  level  as  the  other. 

§  5.  Prognosis. 

It  was  for  a  long  time  thought,  and  still  is,  by  some  persons,  that  a 
delivery  by  the  face  cannot  take  place  by  the  powers  of  nature  alone,  and 
it  is  only  since  the  labors  of  Boer,  of  Chevreul,  and  Madame  Laehapelle, 
that  the  expulsion  of  the  child  in  the  face  positions  has  been  admitted  to  be 
spontaneous  nearly  as  often  as  it  is  in  the  vertex  positions. 

Nevertheless,  we  must  remark  that,  as  a  general  rule,  the  labor  is  more 
tedious,  more  painful,  and  more  dangerous,  both  to  the  mother  and  the 
child,  and  that  it  much  oftener  demands  the  intervention  of  art.  Besides, 
the  reflections  above  presented  would  naturally  lead  us  to  anticipate  that 
the  mento-posterior  positions  are  much  more  unfavorable  than  the  anterior 
ones.  Now,  this  unusual  delay  is  not  because  the  greatest  diameters  of  the 
head  then  present  to  those  of  the  pelvis,  as  Capurou  and  many  others  sup- 
posed: for  it  is  only  necessary  to  bear  in  mind  the  relations  before  indicated, 
to  understand  that  it  is  the  mento-bregmatic,  and  the  bi-temporal  diameters 
(the  one  three  inches,  and  the  other  three  inches  and  three-quarters  in 
iengih),  which  are  then  found  to  correspond  with  the  diameters  of  the 


346  LABOR. 

straits ;  but  because  the  dilatation  of  the  os  uteri  takes  place  more  slowly, 
and  because  the  expulsive  forces,  especially  in  the  process  of  flexion  and  of 
disengagement,  act,  like  the  arm  of  a  lever  which  is  bent,  nearly  at  a  right 
angle.  Moreover,  it  has  already  been  stated  that,  in  all  other  than  vertex 
positions,  a  very  large  quantity  of  the  amniotic  liquid  usually  existed  between 
the  presenting  part  and  the  inferior  segment  of  the  uterus.  We  have  also 
remarked  (see  the  Physiological  Phenomena  of  Labor),  that  this  circumstance 
singularly  influenced  the  rapidity  of  the  dilatation  of  the  os  uteri  On  the 
other  hand,  it  is  also  evident  that,  when  the  chin  is  actually  engaged  under 
the  symphysis,  and  the  process  of  flexion  has  already  commenced,  the  force 
of  the  contraction  transmitted  through  the  spine  can  only  determine  the 
successive  disengagement  of  the  forehead,  the  bregma,  and  the  occiput,  by 
describing  a  well-marked  flexure,  and,  consequently,  thereby  losing  a  large 
proportion  of  its  force.1 

Certain  authors,  say?  Gardien,  have  incorrectly  supposed  that  those 
labors  in  which  the  child  presents  by  the  forehead  are  more  unfavorable 
than  those  where  it  offers  by  the  face ;  for,  if  attention  be  directed  to  this 
point,  the  head  will  then  he  found  to  present  in  reality  by  its  favorable 
diameters ;  and  further,  as  M.  Stoltz  remarks,  in  the  face  positions,  the 
forehead  is  already  the  lowest  part,  and,  the  more  it  descends  when  the 
head  engages,  the  more  easy  will  be  the  labor.  Again,  the  chin  presenta- 
tions are  less  favorable  than  those  of  the  forehead,  because  the  child's  head 
is  then  in  the  most  perfect  state  of  reversion,  and,  if  the  shoulders  engage 
at  the  same  time  w7ith  the  vertical  diameter  of  the  cranium,  a  wedging  in 
must  inevitably  take  place  in  the  excavation.  But  even  these,  also,  soon 
transform  themselves  into  true  face  presentations. 

As  regards  the  foetus,  the  labor,  if  tedious,  may  prove  very  disastrous ; 
since  apoplexy,  or  at  least  a  cerebral  plethora,  and  a  disposition  to  convul- 
sions, are  but  too  often,  says  Madame  Lachapelle,  its  unfortunate  result. 
The  repeated  and  prolonged  compression  of  the  child's  neck,  a  compression 
which  occurs  just  at  the  moment  when  the  head  is  clearing  the  cervix  uteri, 
or  the  superior  strait,  or,  still  more  probably,  when  the  front  of  the  neck  is 
placed  under  the  symphysis  pubis,  satisfactorily  accounts  for  the  difficulty 
in  the  return  of  the  venous  blood,  and  the  cerebral  congestion  which  it 
occasions.  Consequently,  particular  attention  should  be  given  to  the  con- 
strained position ;  for  a  case  that  might  be  abandoned  to  nature,  were  the 
mother  alone  regarded,  would  require  the  intervention  of  our  art,  to  relieve 
the  foetus  from  its  painful  situation.  In  cases  of  this  kind,  where  the  face 
had  descended  enough  to  be  in  full  view  at  the  vulva,  Madame  Lachapelle 
was  in  the  habit  of  judging  by  the  movements  of  the  infant's  tongue  and 
lips;  though  it  must  not  be  forgotten  that  these  motions  are  not  constant 
but,  when  they  do  exist,  and  are  found  to  grow  weaker,  and  finally  to  dis- 
appear, they  constitute  a  bad  sign,  and  claim  our  immediate  attention 
Furthermore,  the  child  often  exhibits  certain  peculiarities  in  face  deliveries, 
which  ought  to  be  known,  in  order  that  the  family  may  be  advised  of  them 
hof'orehand.  The  face  corresponds  to  the  open  space  in  the  excavation,  as 
also  for  a  long  time  to  the  void  under  the  pubic  arch ;  and  hence,  it  becomes 
affected  with  the  ecchymosis  and  the  sero-sanguineous  infiltration  before 
spoken  of  as  happening  in  vertex  presentations. 


Plate  VI. 


Fig.  3. 


I'ii.2. 


Fi|.4. 


Fi|>l. 


Cti~r<nu  and  Titrnier's  Ohxtetrir*. 


PLATE   VI. 

Supplementary   diagnosis   of   the   course   of   labor,    from   the    shape   of    the 
skull  of  the  newborn  child. 

(After  Olshausen.) 

Fig.  i. 
Occipital  presentation. 

Fig.  2. 
Face  presentation. 

Fig.  3. 
Brow  presentation. 

Fig.  4. 
Antero-Frontal  presentation. 


MECHANICAL    PHENOMENA    OF    LABOR. 


347 


Consequently,  when  the  labor  has  been  somewhat  tedious,  the  infant's 
face  at  birth  is  nearly  black,  its  cheeks  swollen,  its  lips  turned  in,  and  the 
nose  scarcely  visible.  However,  this  condition  is  generally  dissipated  in 
the  course  of  a  few  days,  and  its  resolution  may  be  hastened  by  the  use  of 
lotions.  No  alarm  need  be  felt  about  the  tendency  observed  in  the  head  to 
fall  backwards,  as  soon  as  the  support  is  withdrawn ;  for,  it  only  regains  the 
attitude  it  had  temporarily  in  the  pelvis.  This  feebleness  of  the  muscles 
of  the  neck  is  due  to  the  prolonged  extension  they  have  undergone,  ami 
ordinarily  disappears  in  the  course  of  two  or  three  days. 

Schatz'  method  of  reducing  the  extended  head  by  external  manipulation,  as 
described  by  Lusk, consists  in  restoring  the  normal  attitudeof  the  body  by  flex- 
ing the  trunk  and  leaving  the  head  to  resume  spontaneously  its  proper  position 
as  it  sinks  into  the  pelvis.  It  is  performed  by  seizing  the  shoulder  and  breast, 
with  the  hand  through  the  abdominal  walls  ;  then  lifting  the  chest  upward  and 
pressing  it  backward  (see  diag. ),  at  the  same  time  steadying  or  raising  the 
breech  with  the  other  hand  applied  near  the  fundus,  so  as  to  make  the  long 
axis  of  the  child  conform  to  that  of  the  uterus,  and,  finally  pressing  the 
breech  directly  downward. 


Flo.  81«.     Diagrams  showing    Schatz's  method  of  converting  face  presentations  into  vertex  presentations. 

ARTICLE   IV. 

PRESENTATION    OF    THE    PELVIC    EXTREMITY. 

"We  have  already  had  occasion  to  state  that  most  accoucheurs  describe 
three  distinct  presentations  of  the  pelvic  extremity  of  the  fetus,  to  wit,  the 
presentations  of  the  breech,  of  the  feet,  and  of  the  knees,  according  as  the 
breech,  the  feet,  or  the  knees  are  the  first  to  engage  in  the  excavation  and 
clear  the  external  parts  of  generation.  We  have  also  explained  why  I  fol- 
lowing the  example  of  .Madame  Lachapelle,  Ant.  Dubois,  P.  Dubois,  and 
others)  we  consider  these  three  as  being  only  slight  modifications  of  the 
true  pelvic  presentation  ;  for  modifications  that  do  not  in  any  wise  change 
the  mechanism  of  the  natural  labor  ought  certainly  to  be  included  under 
one  and  the  same  title. 


34<S  LABOR. 

Thus,  it  may  happen,  in  presentations  of  the  pelvic  extremity,  that  this 
extremity,  composed  of  all  its  elements,  that  is  to  say,  of  the  thighs  flexed 
on  the  abdomen,  and  the  legs  on  the  thighs,  may  engage  in  the  excavation 
and  inferior  strait;  or  that  the  lower  extremities,  carried  along  when  the 
membranes  are  ruptured,  by  the  gush  of  the  waters,  may  he  completely  or 
partially  unfolded  :  the  feet  in  the  former  case,  and  the  knees  in  the  latter. 
appearing  first  externally;  or  that, the  inferior  members  being  stretched  out 
ami  applied  to  the  child's  anterior  plane,  the  breech  alone  may  descend  ;  or 
lastly,  that  one  of  the  lower  limbs  may  be  extended  up  along  the  abdomen, 
while  the  other  remains  down,  and  then  one  foot  or  one  knee,  as  the  case 
may  be,  will  present  at  the  vulva.  We  shall  include  all  these  varieties 
under  the  general  name  of  the  presentation  of  the  pelvic  extremity;  and  we 
again  repeat  that,  in  the  presentations  of  this  extremity,  the  points  of 
departure,  taken  on  the  foetus,  are,  the  posterior  face  of  the  sacrum  for  the 
breech ;  the  anterior  face  of  the  tibias  for  the  knees  ;  and  the  heels  in  the 
footling  cases.  With  regard  to  the  pelvis,  the  sacrum,  or  the  back  of  the 
child,  may  be  found  in  relation  with  any  one  of  the  various  parts  of  its 
superior  strait ;  but  still,  all  these  shades  of  position  are  included  in  two 
principal  ones,  namely,  a  first,  or  left  sacro-iliac,  and  a  second,  or  right 
sacro-iliac  position ;  and,  further,  each  of  these  exhibits  its  anterior,  trans- 
verse, and  posterior  varieties. 

The  presentations  of  the  pelvic  extremity  are  less  frequent  than  those  of 
the  vertex,  though  much  more  common  than  those  of  the  face.  Thus,  in 
thirty-seven  thousand  eight  hundred  and  ninety-five  labors,  Madame 
Lachapelle  has  noted  one  thousand  three  hundred  and  ninety  of  this  class ; 
in  twenty  thousand  five  hundred  and  seventeen,  Madame  Boivin  observed 
six  hundred  and  eleven;  and  in  two  thousand  and  twenty,  M.  P.  Dubois 
met  with  eighty-five.  In  order  to  give  an  idea  of  the  relative  frequency  of 
the  cases  in  which  the  nates,  the  knees,  or  the  feet  are  first  expelled,  we  will 
add  that,  in  those  eighty-five  labors,  the  nates  appeared  first  at  the  vulva 
fifty-four  times,  and  the  feet  twenty-six  times.  The  presentation  of  the 
knees,  so  called,  was  not  observed  in  a  single  instance.  In  fact,  this  is  a 
very  uncommon  variety  ;  for  in  the  thirty-seven  thousand  eight  hundred  and 
ninety-five  cases  oi  Madame  Lachapelle,  the  knees  came  down  first  only 
eleven  times,  or  one  in  three  thousand  four  hundred  and  forty-five. 

In  a  sum  total  of  sixteen  thousand  six  hundred  and  fifty-four  labors,  Dr. 
Collins  has  observed  the  pelvic  extremity  to  offer  once  in  thirty  times ;  and 
Eamsbotham,  Jr.,  from  calculations  founded  on  twenty-seven  thousand 
seven  hundred  and  thirty-nine  labors,  and  twenty-eight  thousand  and  forty- 
three  births,  occurring  at  the  Maternity  Hospital  of  London,  has  arrived 
at  the  conclusion  that  breech  presentations  are  to  the  others  as  one  to  thirty- 
live.  The  left  sacro-iliac  positions  are  far  more  frequent  than  the  right ; 
thus,  in  thirteen  hundred  and  ninety  instances,  the  back  looked  towards 
the  left  side  seven  hundred  and  fifty-six  times,  and  to  the  right,  four  hun- 
dred and  ninety-four  times ;  but  thirteen  times  in  front,  and  twenty-six 
times  directly  backwards  (Lachapelle).     In  the  eighty-five  positions  of  M. 


MECHANICAL     PHENOMENA    OF    LABOK.  34.9 

P.  Dub:is,  the  back  was  forty-one  times  towards  the  mother's  left,  and 
forty-four  times  to  her  right.  As  to  the  varieties  exhibited  by  these  two  posi- 
tions, the  left  anterior  is  a  little  more  frequent  than  the  right  posterior  one, 
but  each  of  them  is  far  more  common  than  all  the  others  put  together. 
For  instance,  in  one  hundred  and  sixty-three  pelvic  presentations,  says  M. 
Naegele,  the  back  was  in  front  and  to  the  left  one  hundred  and  twenty-one 
times,  whilst  it  was  only  forty  times  behind  and  to  the  right. 

§  1.  Causes. 

It  is  wholly  impossible,  in  the  present  state  of  the  science,  to  say  why  the 
breech  should  sometimes  present  at  the  superior  strait;  true,  numerous 
explanations  have  been  offered,  and  the  following,  proposed  by  Madame. 
Lachapelle  and  reiterated  by  Velpeau,  is  perhaps  the  least  objectionable 
of  any.  The  child,  they  say,  floats  comparatively  free  in  the  uterus,  until 
near  the  eighth  month ;  then  its  head,  during  certain  movements  on  the 
part  of  the  mother,  the  act  of  lying  down  in  particular,  is  carried  towards 
the  fundus  uteri ;  and,  if  the  infant  has  then  acquired  a  considerable  vol- 
ume, perhaps  its  great  occipito-coccygeal  diameter  cannot  repass  through 
the  small  diameters  of  the  uterine  ovoid,  without  undergoing  as  forcible  a 
movement  as  that  which  changed  its  position ;  and  if  this  latter  does  not 
occur,  the  foetus  will  retain  its  new  attitude,  and  at  the  time  of  the  labor 
the  pelvic  extremity  will  present  at  the  passage.  This  explanation,  I 
repeat,  although  liable  to  many  objections,  still  appears  the  most  probable. 

§  2.  Diagnosis. 

[Breech  presentations  may  be  recognized  by  the  successive  employment  of  pal- 
pation, auscultation,  aud  the  tuuch. 

Palpation,  in  accordance  with  the  rules  given,  will  enable  us  to  feel  the  head  at 
the  upper  part  of  the  uterus  ;  and,  if  it  can  be  clearly  made  out,  leaves  little  doubt 
as  regards  the  diagnosis.  If,  however,  the  walls  of  the  abdomen  be  thick,  or  those 
of  the  uterus  rigid,  the  cephalic  and  pelvic  extremities  may  be  mistaken  for  each 
other,  especially  if  we  should  happen  to  feel  the  latter  by  its  posterior  or  sacral 
surface.  But  moderate  importance  ought,  therefore,  to  be  attached  to  this  kind  of 
exploration,  though  it  is  nevertheless  true  that  it  has  its  advantages.  We  rem  em 
ber  a  case  in  which  both  auscultation  and  the  touch  seemed  to  indicate  a  vertex 
presentation,  whilst  palpation  enabled  us  to  feel  the  head  at  the  fundus  of  the 
uterus,  and  the  child  was  born  by  the  breech. 

Auscultation  may  also  enable  us  to  recognize  breech  presentations,  for  in  this 
case  the  dorsal  region  of  the  foetus  is  pretty  high  up,  and,  in  consequence,  the 
maximum  of  the  pulsations  of  the  heart  are  higher  than  in  head  presentations. 
The  loudest  sound  will  generally  be  heard  on  or  above  a  horizontal  line  passing 
through  the  umbilicus,  and  the  side  of  the  abdomen  at  which  it  is  perceived  will 
also  indicate  the  point  toward  which  the  back  is  directed.  The  diagnoses  of  both 
presentation  and  position  are  thus  made  at  the  same  time.] 

To  the  foregoing  signs  may  be  added  the  following  as  distinguishable 
during  labor.  The  bag  of  waters  is  very  large,  and  projects  considerably 
into  the  upper  part  of  the  vagina  ;  sometimes  assuming  the  form  of  an  elon- 
gated tumor,1  which  may  descend,  even  to  within  a  short  distance  of  the 
vulva. 

1  Certain  writers  have  evidently  been  in  error  in  giving  this  particular  form  of  the 
amniotic  sac  as  a  positive  sign  of  a  presentation  of  the  pelvic  extremity,  since  it  may 


350  LABOR. 

When  the  membranes  are  ruptured,  a  very  considerable  quantity  ot 
water  escapes,  for  the  presenting  part  fills  up  the  neck  but  very  imperfectly, 
and  hence,  all  the  amniotic  liquid  flows  out ;  and  if  the  rupture  should 
occur  during  a  strong  pain,  it  would  probably  be  accompanied  by  a  loud 
report. 

Stein  described  the  uterine  orifice  as  being  oval  after  the  rupture,  and 
Madame  Lachapelle  confirmed  this  sign;  but  I  must  confess  that  I  have 
found  great  difficulty  in  verifying  it. 

A  momentary  suspension  or  a  diminution  of  the  pains  often  results  from 
a  too  copious  or  a  too  rapid  discharge  of  the  waters ;  and,  further,  a  flow  of 
meconium  most  generally  takes  place  soon  after  the  membranes  give  wray.x 

But  the  only  characteristic  signs  are  those  furnished  by  the  touch  ;  and 
they  will  vary  with  the  presenting  part.  Therefore,  although  we  have  in- 
cluded, so  far  as  the  mechanism  is  concerned,  all  the  cases  in  which  either 
the  nates,  the  feet,  or  the  knees  present,  under  one  general  term ;  yet,  in  the 
diagnosis,  we  must  carefully  distinguish  them  from  each  other. 

1.  When  the  breech  alone  presents,  the  finger  first  encounters  a  soft, 
rounded  tumor,  upon  some  portion  of  whose  anterior  surface  a  hard,  resist- 
ant part,  formed  by  the  great  trochanter  of  the  thigh-bone,  is  detected. 
Thus  far,  it  might  be  mistaken  for  a  vertex  presentation  ;  but  if  the  finger 
be  next  carried  upwards  and  backwards,  so  as  to  reach,  as  it  were,  the 
sagittal  suture,  it  will  penetrate  into  the  fissure  between  the  nates,  at  the 
bottom  of  which  the  most  important  diagnostic  signs  are  discovered ;  for 
the  point  of  the  coccyx  is  felt  towards  one  side,  surmounted  by  an  irregular 
osseous  surface,  constituted  by  the  posterior  face  of  the  sacrum  ;  then  the 
anus,  a  small,  rounded,  and  wrinkled  orifice,  into  which  the  finger  cannot 
be  introduced  without  resorting  to  considerable  force,  whatever  authors  may 
say  to  the  contrary  ;  lastly,  the  external  genital  organs  can  be  easily  distin- 
guished, and  thereby  the  sex  of  the  child  may  be  announced  in  advance.2 

The  prominence  of  the  coccyx  is  not  only  a  certain  sign  of  the  presenta: 
tion.  but  it  may  also  serve  to  determine  the  position  ;  because  its  point  is 
always  directed  towards  the  side  not  corresponding  with  the  child's  back. 

be  met  with  in  other  cases.  I  have  twice  observed  it  myself  in  clear  vertex  presenta- 
tions that  were  engaged,  even  then,  as  far  as  the  middle  of  the  excavation.  I  can  only 
explain  this  last  circumstance  by  supposing  an  extreme  laxity  of  the  membranes. 

1  However,  a  discharge  of  meconium  may  take  place  in  other  than  pelvic  presenta- 
tions ;  but  then  it  is  an  alarming  sign,  and  one  that  should  receive  the  accoucheur's 
immediate  attention.  In  fact,  it  always  indicates  the  death,  or  at  least  a  suffering 
condition,  of  the  child;  and,  therefore,  will  most  generally  require  the  intervention  of 
art,  since  it  is  particularly  apt  to  come  on  when  the  labor  has  continued  a  long  time 
after  the  rupture,  and  the  foetus  is  suffering  from  the  protracted  delay  ;  or  possibly  it 
may  announce  the  compression  of  the  umbilical  cord  (see  Prolapsus  of  the  Cord). 

2  The  accoucheur  ought  to  be  exceedingly  careful  not  to  deceive  himself  on  this 
point;  and,  in  case  of  any  doubt,  it  would  be  much  better  to  abstain  from  all  predic- 
tions, than  to  expose  himself  to  an  error  that  would  most  certainly  be  retorted  upon 
him  afterwards.  It  is  also  prudent,  where  the  child  is  ascertained,  by  the  touch,  to 
be  of  a  sex  different  from  what  the  family,  and  more  especially  from  what  the  mother 
desires,  not  to  communicate  the  result  of  his  diagnosis,  lest  the  disappointment  she 
would  experience  might,  like  any  other  acute  moral  emotion,  exercise  an  unfavorable 
influence  over  the  progress  of  her  labor. 


MECHANICAL    PHENOMENA    OF    LABOR.  351 

2.  Where  the  two  feet  present  together  in  the  vagina,  it  is  impossible  to 
confound  them  with  any  other  part,  and  the  direction  of  the  heels  then 
clearly  indicates  the  child's  position.  But  where  a  single  foot  only  is 
detected,  and  that  very  high  up,  it  might  be  mistaken  for  a  hand.  How- 
ever, a  little  attention  will  serve  to  distinguish  them ;  thus  the  toes  are 
arranged  in  the  same  line,  are  shorter,  and  less  movable ;  while  the  fingers 
are  longer  and  the  thumbs  separated  from  the  others  ;  the  internal  border 
of  the  foot  is  much  thicker  than  the  external ;  but  the  two  margins  of  the 
hand  are  very  nearly  of  the  same  thickness ;  again,  the  foot  articulates 
with  the  leg  at  a  right  angle,  while  the  hand  continues  out  the  line  of 

the  arm. 

The  diagnosis  is  very  difficult  when  the  feet  present  along  with  the  nates, 
and  they  alone  are  accessible.  Sometimes  even  only  one  foot  can  be  felt, 
which  renders  the  case  still  more  obscure ;  then  we  have  first  to  ascertain 
which  is  the  foot  touched ;  though,  for  that  purpose,  it  is  only  necessary  to 
pay  attention  to  the  relation  existing  between  its  internal  border  and  the 
heel.  For  instance,  let  us  suppose'  that  the  latter  is  turned  towards  the 
symphysis  pubis,  and  its  internal  border  to  the  right  side  of  the  mother ; 
this  is  evidently  the  right  foot;  if,  on  the  contrary,  the  heel  be  directed 
towards  the  sacro-vertebral  angle,  and  the  internal  border  to  the  right,  this 
would.be  the  left  foot,  &c. ;  now,  the  right  foot  being  once  distinguished 
from  the  left,  it  only  remains  to  determine  towards  what  part  of  the  superior 
strait  the  points  of  the  toes  are  directed  (bearing  in  mind  that  we  always 
suppose  the  inferior  extremities  to  be  flexed  on  the  abdomen,  and  the  feet 
crossed  and  turned  inward).  In  this  position  of  the  child,  if  the  toes  of  the 
right  foot  are  turned  towards  any  point  of  the  anterior  half  of  the  pelvis, 
the  back  will  be  directed  to  some  part  of  the  left  lateral  half;  but  if  the 
toes  on  the  left  foot  point  towards  the  anterior  part  of  the  pelvis,  the  child's 
back  will  look  to  some  point  on  the  right  lateral  half,  and  vice  versa. 

[We  think  the  following  the  easiest  way  of  distinguishing  the  right  foot  from  the 
left  one  :  First,  make  sure  of  the  position  of  the  toes,  heel,  and  inner  edge  of  the 
foot  in  question.  Then  let  the  observer  imagine  his  own  foot  in  precisely  the  same 
position,  with  the  heel,  inner  edge,  and  toes  superposed,  as  it  were,  upon  it.  Should 
his  right  foot  correspond,  he  will  diagnose  a  right  foot,  but  a  left  o-ne,  should  it 
require  the  left  foot  to  satisfy  the  conditions.] 

3.  The  knees  very  rarely  present  first ;  besides,  they  have  such  well- 
marked  characteristics  in  their  form,  their  roundness,  their  hardness,  the 
size  of  the  limbs  attached,  and  the  fold  of  the  ham  which  surmounts  them, 
a  fold  presenting  a  transverse  concavity  instead  of  the  convexity  exhibited 
at  the  elbow  and  instep,  that  we  consider  it  useless  to  dilate  further  upon 
their  diagnosis. 

§  3.  Mechanism. 

As  the  left  anterior  and  the  right  posterior  are  the  most  frequent  of  the 
three  varieties  admitted  for  both  the  left  and  the  right  sacro-iliac  positions, 
we  shall  select  them  as  the  type  of  our  description. 

1.  Mechanism  of  Natural  Labor  in  the  Left  Anterior  Sacro-iliac  Position, 
(The  first,  of  authors.) 


352 


LABOR. 


Fig.  82. 


Before  the  rupture  of  the  membranes,  all  the  parts  of  the  child  are  folded 
up  along  its  anterior  plane;  the  head  is  slightly  flexed  on  the  chest,  the 
arms  are  applied  to  the  sides  of  the  thorax,  the  fore-arms  are  bent  on  the 
breast,  and  the  inferior  members  flexed  on  the  front  of  the  abdomen.  In 
ihe  position  before  us,  the  back  of  the  foetus  looks  forward  and  to  the 
mother's  left ;  its  anterior  plane  behind  and  to  her  right ;  its  left  side  is  in 
front  and  to  the  right,  and  the  right  side  behind  and  towards  the  left ;  the 
greater  or  bis-iliac  diameter  of  its  hips  corresponds  to  the  right  oblique,  and 
its  sacro-pubic  or  antero-posterior  one  to  the  left  oblique  diameter. 

[a.  First  Stage.     Moulding  of  the  Breech. — The  first  effect  of  the  contractions  is 

to  curve  the  foetus  upon  its  anterior  plane, 
and  compress  the  lower  extremities  upon  the 
breech,  so  as  to  mould  these  parts  into  a  mass 
small  enough  to  engage  in  the  cavity  of  the 
pelvis.  The  pressure  really  lessens  the  size  of 
the  breech,  and,  at  the  same  time,  adapts  it 
better  to  the  opening  of  the  superior  strait. 
Although  the  diminution  of  bulk  is  greatest 
after  the  membranes  are  ruptured,  the  escape 
of  the  waters  is  also  liahle  to  be  accompanied 
by  an  extension  of  the  lower  limbs,  giving  rise 
to  the  varieties  known  as  foot  and  knee  pre- 
sentations, the  only  effect,  however,  being  to 
facilitate  the  descent. 

This  stage  is  analogous  to  the  first  one  in 
vertex  presentations  ;  only  the  diminution  of 
size,  in  this  case,  is  real  and  sufficient  to  allow 
the  breech  to  descend  into  the  pelvis ,  whilst 
in  vertex  presentations,  the  slightly  compress- 
ible head  is  only  enabled  to  do  so  by  a  sort  of 
mechanical  artifice,  whereby  the  act  of  flexion 
causes  it  to  present  the  diameters  most  favorable  to  its  engagement.] 

b.  Second  Stage.  Engagement. —  If  the  os  uteri  be  freely  dilated  when 
the  rupture  takes  place,  the  nates  immediately  engage  by  traversing  the 
cervix,  and  descend  rapidly  into  the  excavation ;  though,  in  the  contrary 
case,  they  remain  high  up  for  a  long  time.  In  proportion  as  the  contrac- 
tions acquire  more  force  and  energy,  the  buttocks  gradually  descend ;  the 
left  sliding  on  the  internal  surface  of  the  obturator  foramen  and  the  obtu- 
rator internus  muscle,  and  the  right  along  in  front  of  the  parts  that  are 
situated  in  the  left  posterior  quarter  of  the  pelvis. 

c.  Third  Stage.  Rotation  of  the  Breech. — Having  arrived  at  the  inferior 
strait,  the  child's  pelvis  undergoes  a  movement  of  rotation  that  carries  the 
left  hip  behind  the  right  ischio-pubic  ramus,  and  the  right  hip  in  front  of 
the  inner  half  of  the  sacro-sciatic  ligament.  The  left  or  anterior  hip  next 
engages  under  the  aforesaid  ramus,  and  is  the  first  to  show  itself  through 
the  vulva  ;  but  it  is  generally  the  right  or  posterior  hip,  which,  advancing 
step  by  step,  and  describing  an  arc  of  a  circle  around  the  anterior  one  as  a 
centre,  and  traversing  the  whole  anterior  surface  of  the  perineum,  first  suc- 
ceeds in  disengaging  itself  at  the  anterior  commissure,  while  the  other 
remains  nearly  immovable  at  the  summit  of  the  arch.    During  the  delivery 


The  presentation  of  the  breech  in  the  left 
anterior  sacro-iliac  position. 


MECHANICAL    PHENOMENA    OF    LABOR. 


35a 


of  the  breech,  the  body  of  the. child,  by  becoming  strongly  engaged  in  the 
excavation,  is  flexed  laterally  on  its  anterior  (left)  side  in  such  a  way  as  to 
accommodate  itself  to  the  curvature  of  the  pelvis.     (Fig.  84.) 

T>.  Fourth  Stage.     Disengagement  of  the  Breech. — As  the  right  buttock 
approaches  the  posterior  commissure  of  the  labia  externa,  and  engages  in 

FlO.  83.  Fig.  8-1 


The  same  position  after  the  internal 
rotation  is  accomplished. 


The  delivery  of  the  breech. 


this  opening,  the  breech,  or  rather  the  bis-iliac  line  of  the  foetus,  which  had 
already  cleared  the  lower  strait  in  a  somewhat  diagonal  position,  now 
assumes  an  exactly  antero-posterior  direction,  so  as  to  correspond  with  that 
of  the  longitudinal  diameter  of  the  vulva.  However,  this  is  not  constant, 
as  the  breech  sometimes  retains  its  diagonal  position  throughout ;  the  thighs 
closely  applied  on  the  belly  already  begin  to  appear,  and,  pending  the  dis- 
engagement, the  fetal  trunk,  by  accommodating  itself,  as  above  stated,  to 
the  direction  of  the  pelvic  axis,  is  strongly  flexed  on  its  anterior  (left)  side. 
The  rotation  executed  by  the  hips,  when  they  reach  the  inferior  strait,  may 
either  be  a  partial  movement,  or  else  one  in  which  the  whole  trunk  partici- 
pates. 

In  the  former  case,  it  can  only  take  place  by  the  aid  of  a  certain  degree 
of  torsion  in  the  lumbar  vertebral  column,  and  then  the  pelvis,  immediately 
after  its  delivery,  undergoes  the  process  of  restitution,  whereby  it  once  more 
regains  its  primitive  diagonal  position. 

As  soon  as  the  hips  are  clear,  the  breast  engages  in  the  excavation,  the 
arms  always  remaining  applied  against  the  anterior  lateral  parts  of  the 
thorax,  and  the  shoulders  soon  arrive  at  the  inferior  strait  in  an  oblique 
position,  supposing  they  have  not  previously  participated  in  the  rotation 
performed  by  the  pelvis  of  the  child. 

The  shoulders  observe  the  same  mechanism  in  disengaging  as  the  hips ; 
that  is,  they  turn  in  such  a  manner  as  to  place  the  anterior  one,  here  the 
left,  behind  the  right  ischio-pubic  ramus,  and  the  posterior  one  just  in 
advance  of  the  left  sacro-sciatic  ligament,  whence  they  both  clear  this 
strait  diagonally ;  but  when  this  is  passed,  and  there  is  no  other  resistance 
than  that  of  the  soft  parts  to  overcome,  they  complete  the  rotation  and 
23 


354 


LABOR. 


become  placed,  the  oue  directly  in  front,  the  other  behind.  As  to  the 
other  parts,  the  sub-pubic  shoulder  and  elbow  are  the  first  to  at  pear  exter- 
nally ;  but  it  is  still  the  posterior  ones  that  are  first  delivered.1 

Prof.  Dubois  contends  that,  in  breech  deliveries,  the  anterior  hip  and  the 
front  shoulder,  in  the  disengagement  of  the  upper  part  of  the  trunk,  are 
expelled  before  the  corresponding  part  in  the  rear;  but  I  may  be  permitted 
to  repeat  again,  that,  although  matters  often  do  occur  in  the  way  described 
by  the  professor,  still  it  has  seemed  to  me  that  the  view  above  given  holds 
true  in  the  majority  of  cases. 

E.  Fifth  Stage.  Rotation  of  the  Head.— Whilst  the  shoulders  are  travers- 
ing the  pelvis  in  the  manner  just  indicated,  the  head,  being  flexed  on  the 
breast,  clears  the  upper  strait  in  the  direction  of  its  left  oblique  diameter: 
that  is,  the  forehead  is  turned  towards  the  right  sacro-iliac  symphysis,  and 
it  retains  that  position  until  it  reaches  the  inferior  strait. 

The  diameters  of  the  head,  which  are  then  found  in  relation  with  those 
of  the  inferior  strait,  will  necessarily  vary  according  to  the  greater  or  less 
degree  of  the  flexion  of  the  head.  For  instance,  when  it  is  only  moderately 
flexed,  which  is  generally  the  case,  the  occipito-frontal  diameter  corresponds 
to  the  left  oblique  one,  the  bi-parietal  to  the  right  oblique,  and  the  axis  of 
the  inferior  strait  traverses  the  head  very  nearly  in  the  direction  of  its 
trachelo-bregmatic  diameter. 

If  we  suppose  the  head  to  be  more  strongly  flexed  on  the  chest,  the 
sub-occipito-bregmatic  diameter  takes  the  place  of  the  occipito-frontal,  and 


Delivery  by  the  breech.    Disengagement  of  the  head  with  the  chin  behind. 

tne  occipito-mental  corresponds  very  nearly  to  the  axis  of  the  inferior  strait. 
In  a  word,  we  find  the  same  relations  as  in  a  vertex  presentation,  only  the 
head  presents  by  its  base  instead  of  its  summit. 

It  then  performs  a  movement  of  rotation,  whereby  the  face  is  carried  into 
the  hollow  of  the  sacrum,  while  the  occiput  gets  behind,  and  the  neck  under 
the  symphysis  pubis  ;  whence  the  sub-occipito-bregmatic  diameter  approaches 
the  antero-posterior  one  very  closely,  still  retaining,  however,  a  certain 
obliquity. 

P.  Sixth  Stage.  Expulsion  of  the  Head. — At  that  time,  the  womb  can  act 
but  very  feebly  on  the  head  (see  Prognosis),  which  is  altogether  down  in  the 
vagina,  or  nearly  so ;  but  the  tenesmus,  says  Velpeau,  occasioned  by  its  pres- 

1  Many  books,  on  the  subject  of  shoulder-delivery,  assert  that  the  arms  are  retained 
tjy  the  ^nrders  of  the  excavation,  and  thereby  get  up  alongside  of  the  head;  though, 


MECHANICAL     PHENOMENA    OF     LABOR.  355 

sure  oq  the  rectum  and  the  bladder,  constrains  the  woman  to  collect  all  her 
powers,  and  to  redouble  her  courage,  and  then  the  contractions  of  the  abdo- 
minal muscles  soon  come  to  the  aid  of  the  powerless  womb  ;  these  forces, 
acting  conjointly,  flex  the  head  more  and  more,  and  whilst  this  process  of 
flexion  is  going  on  around  the  neck  or  the  sub-occipital  region  as  a  centre, 
the  chin,  the  forehead,  the  bregma,  and  occiput  will  be  found  to  appeal 
successively  in  front  of  the  anterior  commissure  of  the  perineum. 

During  the  flexion,  the  head  represents  a  lever  of  the  first  kind,  whose 
power  is  at  the  occiput,  the  fulcrum  at  the  sub-occipital  point,  or  that  por- 
tion of  the  neck  situated  under  the  arch,  and  the  resistance  at  the  chin,  or 
rather  at  the  forehead,  which,  being  arrested  by  the  perineum,  must  distend 
the  latter  and  render  it  thinner.  Hence,  if  radii  be  drawn  from  the  sub- 
occipital point  of  the  head,  situated  beneath  the  symphysis,  as  a  centre,  and 
terminating  at  the  median  line  of  the  face  and  vault  of  the  cranium,  those 
radii  will  exactly  represent  the  diameters  which  successively  clear  the 
antero-posterior  one  of  the  inferior  strait ;  the  principal  of  which  are  the 
sub-occipito-mental,  the  sub-occipito-frontal,  and  the  sub-occipito-bregmatic. 

2.  Mechanism  of  Natural  Labor  in  the  Might  Posterior  Sacro-iliac  Position. 
(Fourth  of  Baudelocque  and  third  of  Capuron.)  —  In  this  position,  the 
child's  sacrum  is  turned  towards  the  right  sacro-iliac  symphysis,  its  back  is 
behind  and  to  the  mother's  right,  and  its  anterior  plane  is  to  the  left,  in 
front ;  the  right  side  looks  forward  and  to  the  mother's  right,  while  the  left 
side  is  behind  and  towards  her  left ;  and  the  great  or  bis-iliac  diameter  of 
the  child's  pelvis  corresponds  to  the  right  oblique  diameter. 

[Here  also  the  mechanism  of  the  labor  may  be  divided  into  six  stages  analogous 
to  those  just  described  for  the  left  sacro-iliac  position,  —  to  which  the  reader  is 
referred  in  order  to  avoid  repetition.] 

Let  us  suppose,  when  the  membranes  are  ruptured,  that  the  lower  extremi- 
ties, swept  along  by  the  gush  of  liquid,  are  completely  unfolded,  and  that 
the  feet  present  first  at  the  vulva.  In  this  case,  the  limbs  are  soon  delivered, 
under  the  influence  of  the  uterine  contractions,  without  offering  any  pecu- 
liarity, and  the  hips  easily  reach  the  inferior  strait,  where  they  engage, 
sometimes  preserving  their  primitive  diagonal  position,  while  at  others  the 
anterior  one  gets  slightly  in  advance  towards  the  symphysis  pubis,  and  the 
other  or  posterior  goes  behind  to  the  median  line  of  the  sacrum. 

The  arms  and  shoulders  present  in  turn,  and  their  disengagement  is  nearly 
the  same  as  in  the  preceding  case. 

After  the  delivery  of  the  shoulders,  the  head  alone  remains  in  the  exca- 
vation, and  its  expulsion  may  take  place  in  several  different  ways ;  some- 
times, indeed,  the  occiput  remains  posteriorly  throughout  the  whole  delivery, 

as  Desormeaux  very  justly  remarked,  this  scarcely  ever  happens  when  the  delivery  is 
left  entirely  to  nature,  and  no  traction  whatever  is  made  on  the  pelvic  extremity; 
consequently,  when  the  labor  progresses  regularly,  the  accoucheur  should  overcome 
the  temptation  to  aid  nature  a  little  by  drawing  on  the  parts,  for  such  imprudent 
traction  must  certainly  straighten  out  the  arms,  since  there  is  no  counteracting  power 
in  these  cases  to  press  them  outwardly ;  for,  being  retained  by  the  friction,  they 
remain  above  the  excavation,  and  the  head  descends  between  them,  rather  than  that 
ihey  mount  up  on  its  lateral  parts:  and  fortunate  indeed  will  it  be  if  extension  of  th* 
'head  is  n  )t  produced  by  these  tractions! 


356 


LABOR. 


though  at  others,  and  indeed  in  the  great  majority  of  cases,  it  comes  round 
in  front  so  as  to  place  itself  behind  the  symphysis  pubis. 

A.  TJie  Occiput  comes  in  Front.  —  This  conversion  may  begin  as  soon  aa 
the  hips  have  cleared  the  inferior  strait ;  thus  it  often  happens,  as  before 
stated,  that  the  whole  foetal  trunk  participates  in  the  rotation  of  the 
haunches,  whence  the  posterior  plane  of  the  child,  which  was  primitively 
situated  behind,  is  brought  in  front  by  describing  a  kind  of  a  spiral,  that 
commences  in  the  hips  and  terminates  at  the  occiput.  The  head  also  has 
participated  in  the  rotation  of  the  trunk,  so  that,  when  the  former  descends 
into  the  excavation,  the  occiput  becomes  placed  behind  the  symphysis  pubis. 

But  when  the  occiput  retains  its  posterior  position,  after  the  delivery  of 
the  trunk,  this  rotation  of  the  head  may  even  take  place  in  the  pelvis  or  at 
the  inferior  strait.  In  such  cases,  after  the  shoulders  are  born,  the  back  of 
the  child  resumes  its  posterior  direction  by  a  sort  of  restitution,  and  the 
head,  remaining  alone  in  the  excavation,  becomes  placed  in  the  direction 
of  the  left  oblique  diameter,  the  occiput  being  behind  and  to  the  right,  and 
the  forehead  or  bregma  towards  the  mother's  left,  in  front.  It  then  per- 
forms a  movement  of  rotation,  by  which  the  occiput,  after  having  traversed 
the  whole  right  lateral  half  from  behind  forwards,  locates  itself  behind  the 

Fia.  86. 


Delivery  by  the  breech;  disengagement  of  the  head.    The  chin  sliding  beneath  the  pubis,  the 
occiput  remaining  behind. 

symphysis,  and  the  forehead,  by  rolling  from  front  to  rear,  is  carried  into 

the  hollow  of  the  sacrum Though,  whatever  may  have  been  the  mode 

by  which  this  mutation  is  effected,  the  labor  terminates,  just  as  in  the  pre- 
ceding case,  as  soon  as  the  occiput  gets  behind  the  pubic  symphysis. 

B.  The  Occiput  remains  behind.  —  When  the  occiput  remains  behind  until 
the  end  of  labor,  the  delivery  of  the  head  may  take  place  in  two  ways :  thus, 
in  the  majority  of  cases,  this  part  engages  in  the  excavation  in  a  state  of 
flexion,  where  it  soon  undergoes  a  very  slight  movement  of  rotation,  which 
carries  the  occiput  towards  the  concavity  of  the  sacrum,  and  the  forehead 
or  bregma  behind  the  symphysis  pubis;  then,  as  the  uterine  contractions 
and  the  abdominal  muscles  force  the  head  to  become  more  and  more  flexed. 


MECHANICAL     PHENOMENA    OF     LABOR. 


357 


the  following  parts  are  found  to  appear  in  succession  below  the  symphysis 
and  through  the  vulva  ;  first  the  whole  face,  then  the  forehead,  the  bregma, 
the  vertex,  and  last  of  all  the  occiput.  The  head  is  therefore  delivered 
by  a  process  of  flexion,  having  the  neck,  as  a  centre,  resting  against  the 
anterior  commissure  of  the  perineum.     (Fig.  86.) 

Finally,  it  may  happen  that,  instead  of  remaining  applied  on  the  fhest 
the  chin  is  arrested,  and  continues  above  the  pubis,  while  the  occiput  is 
carried  more   and    more   backwards 

by  a  well-marked  movement  of  exten-  FlQ- S7- 

sicn.  The  head  engages  in  the  strait 
by  its  occipital  extremity,  which  then 
traverses  the  whole  posterior  part  of 
the  excavation  by  a  see-saw  move- 
ment, and  is  born  first  at  the  perineal 
commissure ;  after  it  come,  succes- 
sively, the  vertex,  the  anterior  fon- 
tanelle,  the  forehead,  and  the  entire 
face.  Consequently,  the  head  disen- 
gages by  a  process  of  extension,  hav- 
ing the  prsetracheloid  region  as  a 
centre,  which  is  placed  at  first  behind, 
and  then  under  the  symphysis  pubis. 
Cases  of  this  kind  are  reported  by 
Leroux,  Michaelis,  and  Asdrubali, 
but  they  are  very  rare  (Fig.  87). — 
The  mechanisvi  of  labor  in  the  left 
transverse,  and  in  the  right  anterior, 
and  right  transverse  sacro-iliac  posi- 
tions, is  analogous  to  that  just  de- 
scribed for  the  left  anterior,  and  of 
the  right  posterior  iliac  position. 

[We  would  observe,  however,  that  the  left  hip,  which  in  all  left  sacro-iliac  posi- 
tions ought  to  appear  under  the  arch  of  the  pubis,  turns  from  right  to  left  in  the 
left  anterior  sacro-iliac  position,  and  from  left  to  right  in  the  left  posterior  sacro- 
iliac-position.  The  right  hip  will,  in  like  manner,  be  found  to  disengage  the  first 
in  the  right  sacro-iliac-position,  by  turning  from  left  to  right  in  the  anterior  variety 
and  from  right  to  left  in  the  posterior  one.] 

§  4.  Prognosis. 

Breech  presentations  are  not,  usually,  much  more  dangerous  than  those 
of  the  head ;  still,  in  order  to  arrive  at  an  intelligent  prognosis,  the  labor 
should  be  studied  in  reference  to  its  effect  upon  the  mother  and  upon  the 
child  respectively.  Though,  from  the  manner  of  its  expulsion  alone,  the 
life  of  the  child  is  seriously  endangered,  the  parturition  is  certainly  less 
exhausting  and  less  painful  for  the  mother. 

1.  As  regards  the  Mother.  —  As  a  whole,  the  labor  is  somewhat  longer  in 
breech  presentations;  though,  fortunately,  the  delay  is  experienced  almost 
exclusively  during  the  first  stage,  and  is  the  cause  of  but  little  additional 
suffering  to  the  mother.  The  slowness  of  the  process  of  dilatation  is  readily 
explained  by  the  conditions  which  have  been  already  pointed  out.     Before 


Delivery  by  the  breech  ;  the  occiput  behind,  and 
disengaging  at  the  posterior  commissure  of  th« 
vulva,  whilst  the  chin  remains  behind  the  pubis. 


358  LABOR. 

the  membranes  are  ruptured,  the  presenting  part,  having  neither  the  firm, 
roundness,  nor  regularity  of  the  top  of  the  head,  cannot  adapt  itself  to  the 
regular  concavity  of  the  inferior  segment  of  the  uterus,  and  being  separated 
from  the  neck  by  a  considerable  amount  of  amniotic  fluid,  is  therefore  in- 
capable of  hastening  its  dilatation.  Should  the  membranes  happen  to  rup- 
ture long  before  the  dilatation  is  completed,  the  size  or  irregularity  of  the 
breech  prevents  its  engaging  readily,  and  the  neck,  not  being  supported  as 
it  is  by  the  top  of  the  head  in  vertex  presentations,  collapses,  and  contracts, 
so  to  speak,  the  opening  which  it  had  just  before  presented.  In  cephalic 
presentations,  on  the  contrary,  the  head  engages  like  a  wedge,  and  each 
expulsive  effort  tends  to  increase  the  dilatation. 

When  the  nick  is  once  thoroughly  dilated,  the  expulsion  has  always 
seemed  to  me  to  be  effected  more  rapidly  than  in  vertex  presentations. 
The  breech,  the  trunk,  and  the  shoulders  are  generally  delivered  with  ease, 
but  the  head  sometimes  meets  with  obstruction,  and  may  be  arrested  at  the 
superior  strait.  Generally,  however,  it  is  detained  for  but  a  short  time;  for 
if  the  efforts  of  the  female  are  not  capable  of  expelling  it,  it  becomes  the 
duty  of  the  accoucheur  to  interfere  promptly,  in  order  to  remove  the  child 
from  the  danger  which  threatens  it.  The  course  to  be  pursued  under  these 
circumstances,  exposes  the  mother  to  no  danger  whatever,  the  entire  risk 
falling  upon  the  foetus. 

As  regards  the  mother,  therefore,  the  breech  presentation  is  perhaps  even 
more  favorable  than  that  of  the  vertex;  I  would  add,  that  it  is  certainly 
more  so  for  her  than  a  face  presentation. 

It  is  important  to  observe,  that  all  the  varieties  of  breech  presentation 
are  not  equally  favorable.  Some  authors  think  that  the  labor  is  usually 
longer  when  the  foetus  presents  by  the  breech  than  when  the  feet  are  the 
first  to  descend  into  the  excavation. 

The  size  of  the  parts  that  constitute  the  pelvic  extremity,  it  has  been 
said,  do  not  permit  it  to  engage  so  readily ;  and  hence,  the  uterine  contrac- 
tions must  operate  a  longer  time  in  order  to  adapt  those  parts  to  the  diame- 
ter of  the  pelvis.  This  is  true ;  but,  as  Madame  Lachapelle  has  observed, 
their  softness  is  such  that,  when  once  engaged,  they  easily  conform  to  the 
passage ;  and  besides,  as  M.  P.  Dubois  declares,  the  greater  their  volume 
is,  the  more  will  the  labor  resemble  that  of  the  vertex  presentations.  Con- 
sequently, the  professor  teaches,  contrary  to  the  opinion  generally  adopted, 
that  a  delivery  by  the  breech  is  far  preferable  to  that  in  which  the  feet 
come  down  first :  the  truth  of  which  proposition  will  be  better  understood 
when  we  shall  have  pointed  out  the  inconveniences  attending  this  latter  cir- 
cumstance. 

A.-  the  footling  presentation  does  not  exhibit  the  same  unfavorable  ap- 
pearances in  respect  to  volume,  it  is  preferred  by  some  persons ;  for  then 
the  foetus,  presenting  by  its  smallest  extremity,  will,  in  their  estimation,  be 
more  easily  expelled,  since  the  dilatation  of  the  parts,  from  being  slow  and 
gradual,  will  be  much  shorter  and  less  painful.  If  you  wish,  they  say,  to 
drive  a  cork  into  the  neck  of  a  bottle,  you  would  present  its  smallest  ex- 
tremity, and  then  it  would  enter  more  readily,  and  the  same  is  true  of  the 
child  in  the  foot  presentations;  for  the  foetal  ovoid  may  be  considered  as  a 
cone,  whose  base  is  at  the  cephalic,  and  whose  summit  is  at  the  pelvic  ex- 


MECHANICAL     PHENOMENA    OF    LABOR.  359 

tremity.  In  the  case  of  the  bottle  this  is  true,  but  only  so,  because  the 
efforts  you  use  to  make  it  penetrate,  will  be  redoubled  as  the  larger  extrem- 
ity approaches  the  neck  of  the  bottle ;  that  is,  the  force  will  increase  with 
the  difficulties  to  be  overcome  ;  but  this  last  condition  does  not  hold  good 
in  the  delivery  by  the  feet.  Because,  as  the  inferior  parts  of  the  child  be- 
come successively  disengaged,  there  is  less  left  remaining  in  the  uterine 
cavity,  and  there  is  even  a  period  when  the  head,  having  reached  the  exca- 
vation, is  almost  entirely  out  of  the  cavity  of  the  cervix;  but  the  uterus, 
during  its  evacuation,  retracts,  and,  like  all  contractile  muscles,  loses  a  great 
portion  of  its  power  by  this  retraction  ;  and  it  is  therefore  just  at  the  mo- 
ment when  the  great  extremity  of  the  cone,  represented  by  the  foetus,  has 
to  overcome  the  resistance  of  the  soft  parts,  that  the  uterine  contractions 
are  the  most  enfeebled,  and  often,  indeed,  they  cannot  aid  at  all  in  the  ex- 
pulsion of  the  foetal  head :  consequently,  the  powers  here  diminish  in  an 
inverse  ratio  to  the  obstacles  in  the  delivery.  If  the  reader  now  recalls 
what  takes  place  in  vertex  presentations,  he  will  readily  comprehend  the 
difference  between  the  two ;  no  doubt,  the  largest  part  of  the  child  then 
presents  the  first,  and  its  expulsion  requires  violent  and  long-continued 
efforts ;  but  remark  that,  up  to  the  moment  when  the  head  clears  the  vulva, 
the  uterus  yet  contains  in  its  cavity  a  considerable  quantity  of  amniotic 
liquid,  and  also  the  largest  part  of  the  fcetal  trunk ;  wherefore,  it  is  still 
sufficiently  distended  not  to  have  lost  its  power  of  contracting,  a  power  that 
can  be  exercised  over  a  large  surface,  and  upon  which  it  is  forcibly  applied 
until  the  end  of  labor.  Again,  the  head  having  once  reached  the  exterior, 
the  parts  which  have  been  freely  dilated  by  its  passage  offer  but  a  feeble  resist- 
ance to  the  expulsion  of  the  trunk  and  lower  extremities ;  and  hence,  the 
retraction  of  the  womb  may  diminish  its  expulsive  forces  without  this  diminu- 
tion having  any  unfavorable  influence  over  the  termination  of  the  labor. 

2.  As  regards  the  Child. — The  delivery  by  the  pelvic  extremity  is  very 
dangerous  to  the  child ;  thus,  the  statistical  results  furnished  by  Madame 
Lachapelle  prove  that,  in  eight  hundred  and  four  presentations  of  this 
class,  one  hundred  and  two  children  are  born  feeble,  and  one  hundred  and 
fifteen  are  still-born:  the  proportion  of  deaths  to  the  whole  being  rather 
more  than  one-seventh ;  whilst,  in  twenty-six  thousand  six  hundred  and 
ninety-eight  vertex  positions,  there  were  only  six  hundred  and  sixty-eight 
still-born  children,  which  gives  one  in  thirty,  or  about  one-thirtieth.  As 
to  the  particular  prognosis  in  each  of  the  three  varieties  of  this  presenta- 
tion, it  has  been  remarked  that,  when  the  buttocks  advance  first,  the  num- 
ber of  deaths  is  about  one  in  eight  and  a  half,  or  a  little  less  than  an 
eighth;  for  footling  presentations,  one  in  six  and  a  half,  rather  less  than 
one-sixth  ;  and  for  the  knees,  one  in  four  and  a  half,  or  not  quite  one-fourth. 
But  M.  P.  Dubois  has  justly  remarked  that  this  proportion  is  not  perfectly 
correct,  since  all  the  children  born  by  the  pelvic  extremity  are  included  in 
the  registers  of  the  Maternity,  without  making  any  allowance  for  circum- 
stances foreign  to  the  position,  but  which  nevertheless  may  have  produced 
the  child's  death.  Therefore,  by  laying  aside  all  the  cases  where  the  chil- 
dren seemed  to  have  been  lost  under  the  influence  of  causes  that  evidently 
did  not  attach  to  the  presentation  itself,  he  has  arrived  at  the  conclusion 
that,  in  delivery  by  the  pelvic  extremity,  about  one  child  in  eleven  dies; 


360  LABOR. 

whilst  in  vertex  presentations,  only  one  in  every  fifty  proved  fatal.     The 
difference  still,  as  here  shown,  is  frightful. 

Other  things  being  equal,  the  labor  is  much  more  dangerous  for  the  foetus 
in  primiparae,  than  in  those  who  have  previously  borne  children ;  because 
the  resistance  of  the  perineum  which  is  sometimes  sufficient  in  the  former 
to  arrest  the  labor,  even  in  vertex'  presentations,  has  here  a  still  greater 
tendency  to  arrest  the  head,  the  uterine  contractions,  as  just  demonstrated, 
being  weaker. 

But  what  is  the  cause  of  the  child's  death?  For  a  long  time  it  was  sup- 
posed that,  when  the  foetus  presented  its  smallest  extremity,  each  part,  as  it 
came  down,  being  more  voluminous  than  the  one  which  preceded  it,  had  to 
overcome  new  resistances ;  that  it  underwent,  in  consequence,  a  certain 
amount  of  compression,  and  this  compression,  being  exercised  from  below 
upwards,  would  necessarily  drive  back  the  fluids,  and  thus  give  rise  to  a 
cerebral  congestion,  the  anatomical  signs  of  which  are  detected  at  the 
autopsy  of  the  little  corpse.  But  this  supposed  pressing  back  of  the  fluids 
is  altogether  inadmissible :  1st.  Because  the  uterine  neck  is  alternately  in  a 
state  of  relaxation  and  constriction,  whilst  such  an  explanation  would 
require  it  to  be  permanently  contracted ;  2d.  Because,  however  great  the 
contraction,  it  would  not  be  sufficient  to  compress  the  large  vessels  situated 
deep  in  the  extremities,  and  in  the  centre  of  the  great  cavities  ;  3d.  Besides, 
by  recalling  what  takes  place  in  the  vertex  and  face  presentations,  we  shall 
see  that  it  is  not  in  the  parts  which  are  still  contained  in,  and  compressed 
by,  the  uterine  cavity,  that  a  more  considerable  afflux  of  fluid  would  be 
likely  to  occur,  but  rather  in  those  which,  from  being  already  free,  are 
thereby  relieved  from  all  further  compression.  AVe  think  this  mortal  con- 
gestion can  be  explained  in  a  much  more  satisfactory  manner  by  a  com- 
pression of  the  cord ;  for,  after  the  breech  is  disengaged,  the  cord  is 
stretched  from  the  umbilicus  to  its  placental  insertion,  and  is  placed,  both 
in  the  excavation  and  uterine  cavity,  between  the  pelvic  wall  and  the  trunk, 
or  even,  a  little  later,  betwixt  this  wall  and  the  child's  head.  Hence,  we 
can  easily  understand  how  liable  it  is  to  be  compressed  ;  and  as  the  delivery 
of  the  upper  parts,  and  more  especially  of  the  head,  often  takes  place  with 
difficulty,  how  this  pressure  may  exist  for  a  long  time,  and  thus  necessarily 
interrupt  the  circulation  in  the  cord.  Indeed,  it  is  now  generally  admitted 
that  the  placenta  is  the  seat  of  the  child's  respiration  ;  or,  rather,  that  the 
blood  of  the  foetus  comes  there  directly  into  contact  with  that  of  the  mother, 
whereby  it  experiences  certain  modifications  closely  analogous  to  those  which 
the  blood  of  the  adult  undergoes  in  the  lungs,  by  its  contact  with  the  atmo- 
spheric air ;  the  circulation  being  interrupted  in  the  cord,  the  foetus  then 
finds  itself  in  the  condition  of  an  adult  deprived  of  respirable  air,  and  it 
dies  asphyxiated  ;  now  it  is  well  known  that  cerebral  congestion  is  one  of 
the  most  constant  anatomical  phenomena  of  this  state.1     I  am  of  the  opinion 

1  Most  of  the  older  writers  have  explained  the  child's  death  somewhat  differently,  in 
these  cases;  thus,  according  to  some,  the  pressure  interrupts  the  circulation  in  the 
umbilical  arteries,  but  leaves  the  calibre  of  the  vein  entirely  free,  whence  the  foetus 
continues  to  receive  blood  through  the  latter,  without  being  able  to  send  it  back  again 
by  the  former;  and  it  then  dies  from  a  superabundance  of  this  fluid,  from  apoplexy. 
Others,  on  the  contrary,  supposed  that  the  stricture  acted  more  particularly  upon  the 
vein,  leaving  the  arteries  free,  and  therefore  that  the  infant  died  of  anaemia  or  syncope 


MECHANICAL     PHENOMENA    OF    LABOR.  361 

that  asphyxia  of  the  foetus  might  take  place  in  still  another  mannei,  and 
yet  without  the  cord  being  necessarily  compressed.  It  was  stated  above, 
that,  when  the  head  gets  down  into  the  excavation,  no  portion  of  the  child 
is  left  in  the  uterine  cavity,  and  the  empty  womb  then  retracts  of  its  own 
accord  ;  which  retraction  determines,  as  is  well  known,  the  separation  of  the 
placenta,  whereby  the  utero-placental  vessels  are  inevitably  torn,  and  the 
foetus  placed  in  the  same  condition  as  if  the  cord  was  compressed,  and, 
should  the  expulsion  of  the  head  be  at  all  delayed,  it  might  die  asphyxiated. 
It  is  not  necessary,  however,  that  the  placenta  should  be  separated  in 
order  to  produce  this  effect ;  for,  as  Van-Huevel  remarks,  if  the  head  be 
retained  for  some  time  in  the  cavity  of  the  pelvis,  the  retraction  of  the  womb 
would  of  itself  obstruct,  or  even  stop  the  utero-placental  circulation,  and 
destroy  the  foetus  by  asphyxia. 

ARTICLE  V. 

PRESENTATION   OF   THE   TRUNK. 

At  the  commencement  of  this  chapter,  we  gave  the  reasons  that  induced 
us,  like  Madame  Lachapelle,  Nsegele,  and  Dubois,  to  admit  but  two  pre- 
sentations for  the  trunk,  and  therefore  shall  not  now  repeat  them ;  for, 
doubtless,  the  reader  will  bear  in  mind  that  all  the  varieties  of  the  trunk 
presentations  may  be  referred  to  the  two  following,  namely,  one  of  the  right 
and  one  of  the  left  lateral  plane. 

When  the  former  presents  at  the  superior  strait,  the  child's  head,  which, 
in  these  cases,  is  taken  as  the  point  of  recognition,  may  be  found  placed 
over  some  portion  of  the  left  lateral  half  of  the  pelvis,  and  this  constitutes 
the  first  position  of  the  right  lateral  plane  (or  of  the  right  shoulder,  Lacha- 
pelle) ;  or,  the  head  may  be  situated  over  some  point  of  the  right  lateral 
half,  and  this  is  the  second  position.  We  have,  therefore,  two  positions  of 
the  right  shoulder,  or  right  lateral  plane ;  and,  in  the  same  way,  there  are 
two  for  the  left  shoulder,  or  left  lateral  plane ;  in  the  one,  the  head  is  to  the 
mother's  left  (the  left  cephalo-iliac),  and  in  the  other  it  is  at  her  right  (the 
right  cephalo-iliac). 

It  is  a  very  common  circumstance  in  trunk  presentations,  to  find  the  arm 
and  hand  hanging  down  in  the  vagina,  or  even  the  latter  appearing  at  the 
vulva.  This,  although  regarded  for  a  long  while  as  a  much  more  serious 
affair  than  a  proper  shoulder  presentation,  should  be  considered  as  very 
nearly  similar  in  its  character  to  the  deflexion  of  the  lower  extremities  in 
certain  cases  of  pelvic  presentation;  the  older  accoucheurs  have  therefore 
erred  in  describing  it  as  a  distinct  variety,  under  the  title  of  the  presenta- 
tion of  the  arm  and  hand,  it  being  merely  an  additional  phenomenon  asso- 
ciated with  the  presentation  of  the  child's  lateral  region,  and  scarcely 
deserving  consideration  as  a  variety  of  these  positions ;  we  shall  see,  further 
on,  wherein  they  were  mistaken  on  this  point  of  doctrine. 

Neither  of  these  theories  will  bear  the  slightest  examination,  since  it  is  all-sufficient  lo 
examine  the  cord,  and  the  intertwining  of  its  vessels,  to  be  convinced  that  this  partial 
compression  cannot  exist,  except  under  peculiar  circumstances ;  that  such  pressure 
must  interrupt  the  circulation,  both  in  the  arteries  and  veins,  and  that  it  neither  aug- 
ments oor  diminishes  the  quantity  of  the  child's  blood.  Death  by  asphyxia,  therefore, 
is  the  only  possible  mode. 


862  LABOR. 

The  tr  ink  presentations  are  comparatively  rare,  being  a  little  less  so,  how- 
ever, than  those  of  the  face ;  thus,  Madame  Lachapelle  met  with  sixty-eight 
cases  in  fifteen  thousand  six  hundred  and-fifty  two  labors,  or  one  in  about 
two  hundred  and  thirty ;  and,  in  the  two  thousand  two  hundred  deliveries 
reported  by  M.  P.  Dubois,  there  were  thirteen  trunk  presentations.  Dr, 
Bland  observed  it  in  the  proportion  of  one  to  two  hundred  and  ten ;  Dr. 
Joseph  Clark,  one  in  two  hundred  and  twelve  ;  Merriman,  one  in  two  hun- 
dred and  fifty-five,  in  his  private  practice ;  M.  Nsegele,  one  in  one  hundred 
and  eighty  ;  and  Dr.  Collins,  one  in  four  hundred  and  sixteen. 

As  to  the  relative  frequency  of  the  presentations  and  positions,  it  would 
appear,  from  the  statistical  tables  of  Madame  Lachapelle,  that  the  right 
shoulder,  or  the  right  lateral  plane,  presents  a  little  more  frequently  than 
the  left ;  and  that  the  dorso-anterior  positions,  that  is,  the  first  one  of  the 
right  shoulder,  and  the  second  of  the  left,  in  which  the  back  corresponds  to 
the  anterior  part  of  the  uterus,  are  more  frequent  than  the  dorso-posterior 
positions,  or  the  first  one  of  the  left  and  the  second  one  of  the  right  shoulder, 
where  the  child's  back  is  directed  towards  the  mother's  loins.     (Nsegele.) 

§  1.  Causes. 

We  have  but  little  to  say  concerning  the  cause  of  trunk  presentations, 
excepting  that  the  smallness  and  mobility  of  the  child,  a  rounded  form  of 
the  uterus  produced  by  a  large  amount  of  amniotic  fluid,  obliquity  of  the 
womb,  or  of  the  straits  of  the  pelvis,  and  distortions  of  the  superior  strait, 
are  generally  regarded  as  predisposing  thereto.  We  can  readily  understand 
that,  in  the  latter  case,  the  contraction  of  the  pelvic  entrance  might  render 
the  engagement  of  the  head  impossible,  and  by  causing  it  to  glide  toward 
one  of  the  iliac  fossae,  favor  a  presentation  of  the  shoulder.  The  insertion 
of  the  placenta  upon  the  neck  of  the  uterus,  also,  seems  to  predispose  to 
presentations  of  the  trunk,  inasmuch  as  out  of  ninety  cases  of  this  character, 
there  were  twenty-one  in  which  the  shoulder  presented.  M.  Danyau  thinks 
that  a  more  plausible  explanation  may  be  found  in  the  shape  of  the  uterus, 
whose  transverse  diameters  he  supposes  to  be  greater  under  those  circum- 
stances than  usual.  In  support  of  his  view,  he  alleges  the  following  case 
of  Dr.  Lecluyse.  A  woman  had  her  children  to  present  the  shoulder  in 
three  successive  labors,  and  on  the  third  occasion,  the  latter  physician  dis- 
covered that  the  womb,  so  far  from  being  pyriform  in  the  vertical  direction, 
was  shaped,  so  to  speak,  like  an  ellipsoid,  whose  major  axis  was  transverse, 
whilst  the  fundus  of  the  organ  was  but  slightly  elevated  above  the  pubis. 

The  same  explanation  was  proposed  long  ago  by  Wigand.  How  is  it  pos- 
sible, says  he,  for  a  well-formed  child,  whose  body  represents  an  oval,  to 
assume,  without  being  compressed  or  incommoded,  an  oblique  or  transverse 
position,  in  a  womb  of  an  ovoid  shape?  Supposing  that,  impelled  by  cer- 
tain causes,  it  should  assume  these  defective  positions  for  a  moment,  what 
magical  power  could  keep  there  a  foetus,  whose  mobility  is  so  highly  favored 
both  by  the  fluid  in  which  it  swims,  and  the  polish  of  the  internal  surface 
of  the  ovum  ?  What  is  there  to  prevent  it,  in  obedience  to  physical  laws, 
from  changing  its  inconvenient  position  by  bringing  its  long  diameter  to 
coincide  with  the  longitudinal  one  of  the  uterus?   No  better  reply,  he  adds 


MECHANICAL  PHENOMENA  OF  LABOR.  863 

can  be  given  to  these  questions,  than  by  admitting  that  these  defective  posi- 
tions are  due  to  an  irregular  shape  of  the  womb,  rather  than  to  the  move- 
ments which  it  may  have  performed. 

Remembering  the  unfortunate  perseverance  with  which  defective  positions 
recur  in  the  cases  of  certain  females,  there  is  a  strong  disposition  to  seek  for 
the  cause  in  a  peculiar  shape  of  the  uterus ;  and  had  a  peculiar  conforma- 
tion of  the  organ  been  discovered  before  the  first  gestation,  it  might,  per- 
haps, be  admitted,  that  notwithstanding  the  development  undergone  during 
pregnancy,  the  irregularity  of  shape  would  be  preserved. 

Still,  we  may  be  allowed  to  ask  whether  the  increase  in  size  transverse] v, 
near  the  end  of  gestation  and  at  the  beginning  of  labor,  may  not  be  the 
effect  rather  than  the  cause  of  the  unfavorable  position  of  the  foetus. 

As  to  the  determining  causes,  the  only  ones  recognizable  are  fortuitous  and 
accidental ;  thus,  any  violent  commotion,  any  trifling  shocks,  kept  up  for  a 
long  time,  such  as  those  produced  by  carriage  riding,  or  by  exercise  on 
horseback,  the  perturbation  from  the  upsetting  of  a  coach,  and  even  sud- 
den fright,  may  change,  according  to  authors,  the  child's  position  in  certain 
cases,  and  convert  spontaneously  a  vertex  presentation  into  one  of  the 
shoulder.  Indeed,  many  accoucheurs  have  supposed  that  irregular  or  par- 
tial contractions  might  convert,  during  labor,  a  favorable  position  in  one  of 
the  trunk ;  this  is  barely  possible.  But  I  cannot  as  readily  admit  the  sup- 
posed influence  which,  according  to  some  others,  those  uterine  contractions 
may  have,  that  torment  the  woman  during  the  last  few  days,  or  sometimes 
even  weeks  of  her  gestation,  and  which  have  before  been  considered  as  the 
preludes  of  labor.  The  following  is  a  case  in  point :  A  patient,  in  whom 
the  foetus  presented  by  the  shoulder  five  times  successively,  had  always 
suffered  from  these  pains  during  the  last  few  days  of  her  pregnancies;  Pro- 
fessor Naegele,  under  whose  care  she  came  on  the  sixth  accasion,  endeavored 
this  time  to  calm  the  pains,  which  again  appeared  with  the  same  energy 
as  in  the  preceding  gestations.  After  the  ineffectual  administration  of 
various  remedies,  he  finally  ordered  opiate  injections,  when,  to  his  great 
satisfaction,  the  spasms  ceased  almost  immediately,  and  were  not  again 
renewed,  and  the  woman  was  delivered  at  full  term  of  a  living  child,  which 
presented  in  a  favorable  position.  But  what  does  this  prove?  simply  that, 
whatever  may  be  the  child's  position,  these  pains,  the  preludes  of  labor,  may 
appear,  and  that  vicious  positions  may  be  reproduced  in  the  same  woman 
with  a  most  deplorable  perseverance.  It  must  be  evident  that  such  contrac- 
tions are  too  feeble  to  change  the  child's  position  in  any  way,  especially 
when  we  remember  that  the  integrity  of  the  amniotic  sac,  and  the  presence 
of  the  waters,  likewise  protect  it  from  any  influence  they  might  have. 

§  2.  Diagnosis. 

There  is  sometimes  reason  to  suspect  a  trunk  presentation,  even  before 
the  commencement  of  labor,  from  the  following  signs  :  the  abdomen  is  much 
larger  in  its  transverse  diameter  than  usual,  and  when  its  walls  are  soft  and 
flabby,  they  can  often  be  depressed  enough  to  detect  the  fetal  head  in  one 
of  the  iliac  fossae,  presenting  there  as  a  hard,  rounded,  and  resistant  tumor; 
then  by  placing  the  hands  opposite  each  other  in  the  lumbar  regions,  ;< 


364:  LABOR. 

greater  and  firmer  resistance  offered  by  the  two  extremities  of  the  foetal 
ovoid  will  be  felt  at  these  points,  and  the  solid  body,  formed  by  the  child, 
may  be  readily  moved  from  side  to  side,  thus  proving  that  its  long  axis  lies 
transversely  above  the  superior  strait.  Finally,  the  tumor  formed  by  the 
head,  in  the  vertex  presentations,  is  no  longer  detected  by  the  vaginal  touch, 
and  it  is  almost  impossible  to  reach  the  presenting  part ;  in  some  rare 
instances,  the  elbow,  or  the  little  hand  of  the  child,  may  be  recognized  and 
bal lotted,  and  this  sign,  accompanied  by  the  first  two,  renders  the  diagnosis 
quite  probable. 

The  form  of  the  abdomen  is  then  very  irregular,  especially  if  the  uterus 
should  contain  but  a  small  quantity  of  amniotic  fluid.  It  has,  however, 
been  observed,  that  after  the  discharge  of  the  waters,  the  longitudinal 
diameter  gradually  becomes  greater  than  the  other  ;  because,  as  M.  Hergott 
remarks,  the  transverse  position  has  no  longer  a  real  existence,  for  the  body 
of  the  foetus  is  so  curved  upon  itself  that  one  of  its  extremities  is  lodged  in 
the  fundus  of  the  uterus,  although  the  other  does  not  correspond  to  its 
orifice. 

[Although  the  use  of  auscultation  in  breech  presentations  is  but  of  doubtful 
advantage,  M.  Depaul  thinks  that  it  may  enable  one  to  arrive  at  a  correct  diagnosis 
when  the  back  of  the  foetus  is  directed  forward.  In  this  case,  he  says,  everything 
is  arranged  favorably  for  the  recognition  of  the  maximum  intensity  of  the  sound, 
which  will  be  found  at  the  anterior  part  of  the  lower  segment  of  the  uterus  as  in 
head  presentations.  In  proportion,  however,  as  the  position  assumes  a  transverse 
direction,  the  difference  becomes  much  more  decided,  inasmuch  as  the  sound,  instead 
of  being  heard  in  a  lessening  degree  toward  the  fundus  of  the  womb,  then  extends 
in  an  almost  horizontal  direction,  from  one  iliac  fossa  to  the  other,  for  example,  and 
will  be  absent  from  a  large  portion  of  the  upper  region  of  the  organ.] 

Though  M.  Depaul's  opinion  is  rational  and  founded  on  fact,  it  is  none 
the  less  true  that  trunk  presentations  would  almost  always  remain  unde- 
tected if  we  had  to  depend  upon  auscultation  for  their  recognition. 

Sometimes,  however,  it  may  prove  a  useful  auxiliary.  If,  for  example,  a 
email  member  of  the  foetus  be  detected  by  the  touch,  and  the  pulsations  of 
the  heart  are  heard  in  the  hypogastric  region,  we  may  conclude  almost  cer- 
tainly that  the  member  belongs  to  the  upper  extremity.  Should  the  heart 
be  heard  on  a  level  with  the  umbilicus,  it  would  most  probably  prove  a 
pelvic  extremity. 

Before  the  membranes  are  ruptured,  the  elevation  of  the  part  renders  the 
vaginal  touch  very  difficult;  and  so,  of  course,  the  form  of  the  bag  of 
waters,  or  that  of  the  uterine  orifice,  can  be  of  but  little  service.  Accord- 
ing to  .Madame  Boivin,  the  os  uteri  dilates  more  slowdy,  but  as  this  slowness 
ul'  dilatation  is  met  with  in  all  presentations,  excepting  those  of  the  vertex, 
it  forms  a  sign  of  minor  importance;  the  touch,  therefore,  can  only  give  a 
positive  certainty  after  the  rupture  of  the  membranes.  When  the  side  is 
the  presenting  part,  the  shoulder  (Lachapelle)  is  very  frequently  found  at 
the  centre  of  the  superior  strait,  as  also  the  elbow,  or  the  side  of  the  chest 
(P.  Dubois),  and  hence  will  be  the  first  encountered  by  the  finger  in  making 
an  examination  ;  and  we  therefore  have  to  point  out  the  characters,  suc- 
cessively, whereby  these  several  parts  may  be  recognized. 


MECHANICAL  PHENOMENA  OF  LABOR.  365 

1.  When  the  shoulder  presents,  the  finger  first  detects  the  rounded  tumor 
formed  by  its  summit,  upon  the  surface  of  which  a  small  osseous  projection, 
constituted  by  the  acromion,  is  distinguished ;  then,  behind  or  in  front, 
according  to  the  position,  the  clavicle  and  the  spine  of  the  scapula  are  felt, 
and  below  the  clavicle  the  intercostal  spaces  are  easily  made  out,  whilst 
under  the  spine  of  the  scapula  there  is  only  a  plane  surface,  terminated 
by  the  acute  inferior  angle  of  this  bone,  which  is  movable  and  permits 
the  finger  to  slip  under  it ;  lastly,  on  the  sides  of  the  tumor  formed  by 
the  shoulder,  the  axillary  space  can  always  be  distinguished,  and  some- 
times also  (though  on  the  opposite  side)  the  depression  in  the  neck  can 
be  felt. 

The  shoulder  being  once  recognized,  we  must  next  determine  which  one 
it  is,  and  what  is  its  position.  I  will  remark,  in  advance,  that  we  have 
admitted  but  four  positions  of  the  trunk,  namely,  two  for  the  right  shoulder 
and  two  for  the  left,  and  that  the  relation  existing  between  the  situation  of 
the  head  and  that  of  the  child's  posterior  plane  is  different  in  each  of  these 
four.  Thus,  there  are  two  positions  where  the  head  is  to  the  left,  namely, 
the  first  position  of  the  right  and  the  first  of  the  left  shoulder ;  and  remark 
that,  in  the  latter,  the  child's  back  is  turned  towards  the  mother's  loins;  in 
the  former,  on  the  contrary,  it  is  in  front ;  and,  therefore,  whenever  the  head 
is  to  the  left  and  the  child's  back  is  behind,  we  have  to  treat  with  a  first 
position  of  the  left  shoulder. 

In  the  same  way,  there  are  two  positions  in  which  the  head  is  to  the 
right,  to  wit,  the  second  of  the  right  and  the  second  of  the  left  shoulder ; 
but  again  observe,  that  in  the  latter  the  back  looks  forwards,  while  in  the 
former,  on  the  contrary,  it  is  directed  posteriorly.  Hence,  to  recognize  a 
second  position  of  the  left  shoulder,  it  will  only  be  necessary  to  ascertain 
that  the  child's  head  is  turned  towards  the  mother's  right  side,  and  that  its 
back  looks  anteriorly.  In  a  word,  to  satisfy  ourselves  which  is  the  present- 
ing shoulder,  and  what  is  its  position,  we  only  have  to  find  out  where  the 
head  lies,  and  the  position  of  the  posterior  plane  of  the  child. 

The  shoulder  presenting  and  being  recognized,  it  is  evident  that  if  the 
axillary  space  looks  towards  the  mother's  right,  the  head  will  be  to  her 
left,  and  vice  versa;  consequently,  the  situation  of  the  head  is  readily  known 
by  the  direction  of  this  space,  and,  as  regards  the  child's  dorsal  plane,  the 
omoplate  will  clearly  indicate  its  position. 

2.  When  the  elbow  alone  is  accessible  to  the  finger,  it  may  be  recognized 
by  the  three  osseous  projections  (the  olecranon  and  the  two  condyles),  which 
it  presents  by  the  transverse  concavity  in  the  bend  of  the  elbow,  and  by  the 
vicinity  of  the  chest  and  intercostal  spaces.  The  elbow  having  been  dis- 
tinguished, it  will  be  necessary  to  make  out  the  position  to  ascertain  where 
the  fcetal  head  and  its  dorsal  plane  lie,  but  this  is  now  comparatively  easy, 
since  the  elbow  is  always  directed  towards  the  side  opposite  to  that  where 
the  head  is  found,  and  the  forearm  is  always  placed  on  the  anterior  plane. 

Again,  as  above  stated,  it  happens  at  times  that  the  forearm  is  not  doubled 
up,  but  that,  on  the  contrary,  the  hand  hangs  down  in  the  vagina,  or  even 
appears  at  the  vulva.  Now,  to  determine  which  is  the  presenting  hand  in 
those  cases,  it  is  necessary  to  turn  it  in  such  a  way  as  to  place  its  pal  mat 


366  LABOR. 

surface  in  front  and  above,  for,  in  this  position,  if  the  thumb  be  directed  to 
the  mother's  right  thigh,  it  is  the  right  hand,  but  if  to  the  left  thigh,  it  is 
the  left  hand ;  and  then,  to  find  out  where  the  head  is,  the  accoucheur  must 
slip  his  finger  up  to  the  axillary  space. 

[The  advice  just  given  would  enable  us  to  recognize  -with  certainty  the  projecting 
hand  ;  the  misfortune  is  that  it  is  so  easily  forgotten.  Therefore  we  think  it  better 
that  the  operator  should  simply  observe  which  of  his  own  hands  would  fulfil  pre- 
cisely the  conditions  of  that  of  the  foetus  as  to  position,  for  then  the  diagnosis  would 
be  just  as  certain,  inasmuch  as,  with  the  exception  of  the  size,  the  right  hand  of  an 
adult  is  formed  precisely  like  the  right  hand  of  the  child,  and  so  with  the  left  hands 
of  both,  whilst  marked  differences  exist  in  the  reciprocal  arrangement  of  the  parts 
composing  a  right  hand  and  a  left  one.] 

When  the  hand  comes  out  at  the  vulva,  a  careful  inspection  of  it  will 
most  generally  be  sufficient  to  establish  the  diagnosis.  Thus,  if  its  dorsal 
surface  is  turned  towards  the  patient's  right  thigh,  the  head  is  at  the  right, 
and  if  to  the  left  thigh,  the  head  is  at  the  left.  The  little  finger,  directed 
towards  the  coccyx,  indicates  that  the  child's  dorsal  plane  corresponds  to 
the  mother's  loins,  and  the  same  finger  pointing  to  the  pubis,  is  an  evidence 
of  this  plane  being  in  front. 

"We  have  been  thus  particular  in  the  diagnosis,  because  it  is  all-important 
in  trunk  presentations  to  understand  clearly  which  side  presents  at  the 
strait,  since  the  accoucheur  must  always  endeavor  to  turn;  and  if  the  details 
just  given  prove  difficult  of  comprehension  from  a  single  reading,  we  hope 
they  will  become  clearer  by  practising  on  a  mannikin. 

§  3.  Mechanism. 

When  the  trunk  presents  at  the  superior  strait,  the  labor  nearly  always 
requires  the  intervention  of  art ;  though,  in  some  rare  cases,  which  may  be 
considered  as  altogether  exceptional,  nature  alone  is  adequate  to  accom- 
plish the  delivery,  which  may  then  take  place  in  one  or  two  ways;  for 
either  the  presenting  shoulder  is  driven  from  the  superior  strait  under  the 
influence  of  the  uterine  contractions  alone,  to  make  room  for  one  of  the 
child's  extremities,  thereby  producing  a  change  in  position,  and  giving  rise 
to  what  is  designated  as  spontaneous  version,  or  else  the  presenting  shoulder 
descends  into  the  excavation  and  engages  at  the  inferior  strait ;  notwith- 
standing which,  the  breech  sweeps  along  the  whole  anterior  surface  of  the 
Bacrum  and  of  the  perineum,  and  is  delivered  the  first  at  the  posterior 
vulvar  commissure ;  this  latter  mechanism  is  called  spontaneous  evolution. 

1.  Spontaneous  Version. — Where  the  membranes  are  not  ruptured,  though 
the  labor  has  actually  commenced,  the  foetus  sometimes  enjoys  a  great  lati- 
tude of  motion  in  the  amniotic  cavity,  in  consequence  of  which  it  might, 
in  such  cases,  readily  change  its  position  before  the  discharge  of  the  waters 
took  place ;  and  it  has  been  known  to  present,  in  this  way,  different  points 
of  it3  surface  during  the  first  period  of  the  labor.  Sometimes  the  head 
ascends  in  the  womb  while  the  breech  descends ;  at  others,  on  the  contrary, 
the  nates  mount  up  towards  the  fundus  uteri,  and  the  head  becomes  located 
at  the  superior  strait.  Consequently,  two  varieties  of  spontaneous  version 
have  been  adnrtted,  i.  e.,  the  cephalic  and  the  pelvic. 


MECHANICAL  PHENOMENA  OF  LABOR.  367 

This  phenomenon  usually  occurs  either  just  before  or  else  soon  after  the 
membranes  are  ruptured;  in  some  instances,  however,  it  takes  place  a  long 
time  after  the  waters  are  discharged.  The  following  case,  reported  by  M. 
Velpeau,  will  give  a  very  correct  idea  of  what  occurs  under  such  circum- 
stances:  "A  young  woman,  pregnant  for  the  second  time,  came  into  the 
hospital  at  ten  o'clock  in  the  morning.  The  os  uteri  was  very  little  dilated; 
nevertheless,  I  could  recognize  a  second  position  of  the  left  shoulder.  The 
waters  did  not  escape  until  three  in  the  afternoon,  and  I  did  not  wish  to  go 
after  the  feet,  as  the  pains  were  neither  very  strong  nor  very  frequent,  and 
I  had  some  confidence  in  the  assertions  of  Denman  on  this  subject.  At 
eight  o'clock  in  the  evening,  the  shoulder  had  sensibly  moved  towards  the 
left  iliac  fossa,  and  I  could  then  readily  detect  the  ear  at  the  right.  At 
eleven,  the  temple  had  almost  gained  the  centre  of  the  orifice ;  the  contrac- 
tions were  augmented  in  energy ;  and  the  cervix  was  entirely  effaced.  At 
midnight,  the  vertex  had  become  lower;  the  head  engaged;  and,  in  the 
course  of  an  hour,  the  vertex  was  delivered  in  the  right  occipito-cotyloid 
position."1 

This  case,  in  which  the  progress  of  the  labor  has  been  followed  and 
described,  step  by  step,  is  well  suited  for  explaining  the  mechanism  of  spon- 
taneous cephalic  version.  The  reader  will  easily  comprehend  that  the  same 
phenomena  would  take  place,  if  the  breech,  instead  of  the  head,  descended 
towards  the  superior  strait ;  and,  in  the  above  instance,  for  example,  the 
shoulder,  instead  of  being  driven  towards  the  left  iliac  fossa,  would  be  forced 
to  the  mother's  right,  and  then  the  side  of  the  chest,  the  loins,  the  left  hip 
and  thigh,  would  successively  appear  at  the  upper  strait,  and  the  breech 
finally  engage  in  the  excavation. 

In  a  shoulder  presentation,  the  arm  and  hand  may  hang  down  in  the 
vagina,  or  even  protrude  beyond  the  vulva  ;  but  this  last  circumstance  does 
not  preclude  the  possibility  of  a  spontaneous  version,  only  it  is  well  to  bear 
in  mind  that  the  arm  may  then  ascend  again  into  the  uterine  cavity,  and 
this  will  almost  certainly  happen  if  the  pelvic  extremity  descends  into  the 
excavation,  but  it  may  also  lodge  on  one  side  of  the  pelvis,  and  thus  permit 
the  head  to  descend  alongside  of  it ;  the  presentation  of  the  cephalic 
extremity  being  then  complicated  by  a  procidentia  of  the  arm  and  hand. 
In  the  present  state  of  our  science,  it  would  be  a  very  difficult  matter 
indeed  to  point  out  the  various  causes,  under  the  influence  of  which  it  is 
sometimes  the  head,  and  sometimes  the  breech,  which  thus,  in  cases  of  spon- 
taneous version,  take  the  place  previously  occupied  by  the  shoulder,  at  the 
superior  strait.  Nevertheless,  I  am  inclined  to  believe  that  irregularity  of 
the  uterine  contractions  is  not  wholly  foreign  to  such  an  effect.  In  fact, 
when  we  shall  speak  hereafter   of  what  the  German  accoucheurs  have 

1  With  regard  to  the  case  in  the  text,  I  may  say  briefly,  that  the  course  of  M.  Velpeau 
was  legitimized  by  the  desire  he  had  of  testing  the  opinions  at  that  time  (1825)  in  dis- 
pute ;  but  young  practitioners  should  be  very  cautions  how  they  make  such  experi- 
ments;  for  although,  in  the  hands  of  a  man  like  Velpeau,  the  version,  at  an  advanced 
period  of  labor,  would  have  been  comparatively  easy,  yet  it  must  never  be  forgotten 
that,  in  trunk  presentations,  the  soonest  possible  period  after  the  rupture  of  the 
membranes  is  the  most  favorable  for  the  artificial  version. 


368  LABOR. 

described  under  the  name  of  Partial  Contraction  of  the  Womb,  it  will  be 
seen  that,  in  some  cases,  the  organ  appears  to  contract  in  but  a  limited  part 
of  its  extent,  the  remainder  contracting  with  much  less  force,  or  even  per- 
haps remaining  entirely  inert.  Now,  without  being  able  to  cite  a  single 
instance  in  support  of  my  opinion,  I  am  strongly  inclined  to  believe,  that 
it  is  in  such  a  condition  of  the  uterine  walls  that  spontaneous  version  would 
he  the  most  likely  to  take  place.  Let  us  suppose,  for  example,  that 
when  the  child  is  placed  in  a  left  cephalo-iliac  position  of  the  right  shoul- 
der, the  left  side  of  the  uterus  alone  contracts,  the  right  remaining  passive ; 
it  is  manifest  that  the  whole  expulsory  effort,  being  then  exercised  on  the 
head,  would  necessarily  depress  it  towards  the  centre  of  the  superior  strait; 
and  this  movement  of  the  cephalic  extremity  will  be  easy,  in  proportion  aa 
the  inertia  of  the  right  lateral  wall  of  the  womb  shall  oppose  no  obstacle  to 
the  elevation  of  the  pelvic  extremity.  But  if,  on  the  contrary,  (in  the  same 
position  of  the  child),  the  right  side  of  the  womb  only  contracted,  it  is 
evident  the  breech  alone  would  receive  the  impulse  from  the  uterine  efforts, 
and  then  a  spontaneous  podalic  version  would  be  observed  to  take  place.1 

2.  Spontaneous  Evolution. — The  mechanism  of  spontaneous  evolution  is 
much  better  understood,  and  we  shall  find  embraced  in  its  descriptions  all 
the  divisions  of  the  mechanism  of  natural  labor  in  the  vertex  and  face  pre- 
sentations. Here,  also,  M.  Velpeau  has  admitted  two  varieties,  that  is,  a 
spontaneous  cephalic,  and  a  spontaneous  pelvic  evolution.  But  Ave  cannot 
conceive  how  a  spontaneous  cephalic  one  can  take  place,  unless  it  be  in 
cases  of  abortion,  or  in  those  where  the  child  is  completely  putrefied ;  hence 
we  shall  treat  of  the  pelvic  variety  alone,  taking,  as  an  example,  the  first 
or  left  cephalo-iliac  position  of  the  right  shoulder,  in  which  the  child's  head 
is  placed  in  the  left  iliac  fossa,  the  breech  in  the  right  iliac  fossa ;  the  dorsal 
plane  being  in  front,  and  the  sternal  one  behind,  and  the  long  axis  situated 
very  nearly  in  the  direction  of  the  transverse  diameter  of  the  upper  strait. 

Under  such  circumstances  nearly  all  the  Avaters  escape  immediately  after 
the  membranes  are  ruptured;  then  the  uterus  contracts  forcibly,  and  by 
compressing  the  foetal  trunk  on  all  sides,  has  a  tendency  to  make  the  pre- 
senting part  engage  in  the  excavation. 

A.  First  Stage.  Doubling  up  of  the  Child. — Under  the  influence  of  the 
uterine  contractions,  the  child  is  sti-ongly  bent  in  the  direction  of  its  long 
axis  towards  the  side  opposite  to  the  presenting  one ;  for  instance,  in  the 
case  before  us,  the  head  is  bent  to  the  left  side,  and  the  breech  towards  the 
hip  of  the  same  side. 

b.  Second  Stage.  Engagement.  —  A  second  stage,  the  period  of  descent, 
then  sets  in  ;  that  is  to  say,  in  proportion  as  the  contractions  are  renewed, 
tli'  -boulder  approaches  more  and  more  towards  the  inferior  strait,  and  the 
foetal  trunk,  being  bent  double,  engages  deeply  in  the  excavation.  But 
the  same  difficulty  is  here  met  with  as  in  the  face  presentations  (see  Posi- 
tion* of  the  Face)  ;  that  is,  the  body  being  thus  placed  transversely,  it  is 
impossible  for  the  shoulder  to  reach  the  lower  strait  unless  the  head  engages 
simultaneously  with  it  in  the  excavation  ;  or,  indeed,  unless  the  neck  should 

1  Taylor  (Am.  Jour,  of  Ob.,  July,  1881)  uses  the  word  rrtraeiion  to  describe  the 
physiological  motive  power  or  action  of  the  uterus,  which  takes  place  after  contrac- 
tion and  during  the  relaxation  by  which  the  shoulder  of  the  child,  or  any  other  part, 
is  lifted  or  drawn  up  or  back  from  its  position  in  the  pelvis. 


MECHANICAL    PHENOMENA    OF    LABOR. 


369 


be  long  enough  to  subtend  the  height  of  the  lateral  wall  of  the  latter,  which 
we  have  already  seen  is  impossible  (see  Mechanism  of  Face  Position*  i.  The 
descent  of  the  shoulder  is  therefore  limited  to  the  length  of  the  neck. 

o.   Third  Stage.     Rotation. — A  movement   of  rotation  next  occurs,   by 


Fio.  89. 


First  position  of  the  right  shoulder  with 
the  arm  hanging  down. 


The  game  position  during  the  descent. 


which  the  long  axis  of  the  child,  that  was  originally  placed  transversely. 
is  brought  very  nearly  into  an  antero-posterior  direction,  so  that  its  cephalic 
extremity  is  placed  above  the  horizontal  branch  of  the  pubis  close  to  the 
spine  of  that  bone,  and  the  breech  above,  or  rather  in  front  of  the  sacro- 
iliac symphysis.  This  process  of  rotation  being  once  effected,  the  descent 
may  now  be  completed,  since  the  side  of  the  neck  is  placed  behind  the 
symphysis  pubis,  whose  whole  length  it  can  subtend;  consequently,  the 
forearm  and  arm  are  found  to  appear  at  the  vulva,  and  the  shoulder  to  get 
under  the  arch  of  the  pubis. 

D.  Fourth  Stage.  Disengagement  of  the  Trunk.  —  The  trunk,  being  now 
bent  double,  is  forced  en  masse  into  the  excavation,  under  the  influence  of 
the  powerful  uterine  contractions,  but  the  shoulder  can  descend  no  further, 
because  it  is  arrested  by  the  shortness  of  the  neck ;  hence,  the  expulsive 
force  acts  on  the  pelvic  extremity,  which  is  pressed  more  and  more  towards 
the  floor  of  the  pelvis,  and  traverses  the  whole  anterior  face  of  the  sacrum. 
It  then  rests  against,  depresses,  and  forcibly  distends  the  perineum;  the 
vulva  soon  dilates,  and  the  acromion  remaining  always  fixed  under  the  sym- 
physis, the  following  parts  are  observed  to  appear  successively  at  the  ante- 
rior perineal  commissure:  tirst,  the  superior  lateral  parts  of  the  chest; 
next,  its  inferior  part,  the  loins,  the  hip,  the  thighs;  and  lastly,  the  whole 
length  of  the  inferior  extremities;  and  there  remain  only  the  head  and  the 
left  shoulder  in  the  excavation.  This  last  movement  may  be  considered  as 
the  fourth  stage  of  the  labor,  and  it  is  therefore  named  the  period  of  deflexion 
or  disengagement.  It  takes  place  around  the  shoulder,  situated  under  the 
symphysis  as  a  centre,  and  therefore,  if  lines  be  drawn  from  this  centre,  ter- 
minating at  the  various  points  on  the  child's  side,  we  shall  have  all  the 
radii,  or  the  foetal  diameters,  which  clear  the  antero-posterior  one  *f  thtf 
inferior  strait. 


870 


LABOR. 


[e.  Fifth  Stage.  Rotation  of  the  Head.  —  "When  by  spontaneous  evolution  the 
body  has  been  disengaged,  the  conditions  have  become  the  same  as  in  breech  presen- 
tations In  the  fifth  stage,  therefore,  the  head  rotates  so  as  to  bring  the  occiput 
behind  the  symphysis  pubis. 

f.  Sixth  Stage.  Expulsion  of  the  Head.  —  In  the  last  stage  the  head  is  delivered 
as  in  breech  cases.] 

Such  is  the  exact  mechanism  of  the  spontaneous  evolution  in  those  e?»ses 
where  the  child's  posterior  plane  was  originally  in  front ;  or,  in  other  words, 

Fib.  90.  Fio.  91. 


Fig.  90.  Position  of  the  child  after  the  rotation,  and  just  at  the  moment  when  thd  process  of  disengagement 
lie^ius. 

Fio.  91.  The  same  position  with  the  delivery  more  advanced. 

in  a  first  position  of  the  right  or  a  second  of  the  left  shoulder,  for  there  is 
no  difference  in  this  last,  excepting  that  the  movement  of  rotation  must 
take  place  in  the  opposite  direction,  that  is,  the  head  must  pass  from  right 
to  left  and  from  behind  forward,  and  the  breech  from  left  to  right  and  from 
before  backwards.  But  when  the  sternal  plane  of  the  foetus  is  primitively 
directed  towards  the  mother's  front,  as  in  the  first  position  of  the  left,  and 
the  second  one  of  the  right  shoulder,  the  process  takes  place  somewhat  dif- 
ferently. M.  P.  Dubois,  who  had  an  opportunity  of  seeing  two  cases  of 
this  nature,  informed  me  that,  at  the  moment  when  the  breech  disengaged 
at  the  anterior  perineal  commissure,  the  child's  whole  trunk  underwent  a 
movement  of  torsion  that  again  brought  its  dorsal  plane  forwards  and  up- 
wards, which  plane,  without  this  process  of  torsion,  would  still  have  been 
directed  towards  the  anus;  whence  we  find,  even  here,  remarkable  as  it 
may  seem,  the  influence  of  that  general  law  which  was  observed  to  regulate 
all  natural  labors,  namely,  that,  whatever  may  have  been  the  original  rela- 
tions of  the  child's  posterior  plane,  it  ultimately  comes  into  correspondence  with 
the  anterior  parts  of  the  pelvis. 

A  variety  of  spontaneous  evolution  is  described  by  Roderer  as  "evolutio 
conduplicato  corpore,"  in  which  the  trunk  is  so  greatly  flexed  that  the  beacl 
and  thorax  enter  the  pelvic  cavity  simultaneously,  and  are  expelled  fol- 
lowed by  the  breech  and  legs.  This  occurs  most  frequently  in  those  cases 
in  which  the  tutus  has  been  softened  by  putrefactive  changes.     Dr.  Taylor 


Plate  VII. 


Ti§.3. 


E& 


Caaeauz  and  Tarnier'i  Obstelru  i. 


PLATE  VII. 


Figs.  1-4. 
The  different  stages  of  Spontaneous  Expulsion. 

(After  Spiegelberg.) 

Fig.  5. 
Labor  with  the  body  bent  double. 

(After  Kleinwachter.) 


MECHANICAL    PHENOMENA    OF     LABOR.  371 

advises  the  division  of  the  perineum  freely  and  laterally,  to  the  extent  of 
three  or  four  inches,  to  allow  the  breech  to  be  delivered,  and  thus  avoid  the 
sacrifice  of  the  child  if  living. 

§  4.  Prognosis. 

We  again  repeat,  for  it  seems  highly  important  that  this  should  be  firmly 
impressed  on  the  mind,  that  in  trunk  presentations  a  spontaneous  expulsion 
of  the  child  is  wholly  an  exception  to  the  general  rule,  and  one  upon  which 
no  reliance  can  be  placed,  unless  in  a  case  of  abortion ;  and  that  the  resources 
>f  our  art  are  demanded  in  every  case  just  as  soon  as  the  neoessary  condi- 
tions exist  for  such  intervention.     (See  Version.) 

In  fact,  by  consulting  the  published  cases,  or  indeed  by  simply  reflecting 
on  the  mechanism  by  which  the  delivery  is  effected,  we  realize  how  this 
must  expose  the  woman  to  a  very  long  and  painful  labor,  and  the  foetus  to 
60  violent  a  compression  that  its  death  must  often  result  in  consequence. 
According  to  the  statistics  furnished  by  M.  Velpeau,  one  hundred  and 
twenty-five  children,  in  one  hundred  and  thirty-seven,  were  still-born.  It 
must  not  be  supposed,  however,  as  some  persons  appear  to  have  done,  that 
this  mode  of  delivery  is  only  possible  in  cases  of  abortion  ;  for  facts  too 
numerous  militate  against  this  opinion  for  it  to  be  any  longer  tenable. 

Burns  justly  remarks,  in  endeavoring  to  demonstrate  the  physical  possi- 
bility, that  the  greatest  diameter  measures  five  inches  and  a  half;  sometimes 
the  distance  is  barely  five  inches,  and  continued  force  may  make  it  less ; 
hence,  provided  the  dimensions  of  the  pelvis  are  slightly  greater  than  in 
their  normal  condition,  there  is  nothing  here  physically  impossible,  as  has 
been  affirmed  and  reaffirmed,  doubtless  without  mature  reflection.  The 
favoring  circumstances  which  render  a  spontaneous  evolution  easier  and 
more  likely  to  take  place  are :  a  premature  labor,  the  smallness  of  the  child, 
a  large  pelvis,  strong  contractions,  diminished  resistance  from  the  soft  parts, 
numerous  antecedent  labors,  and  the  readiness  with  which  the  woman  has 
heretofore  been  delivered  of  large-sized  children.  The  opposite  circum- 
stances would  render  it  exceedingly  difficult,  if  not  wholly  impossible. 

ARTICLE    VI. 

REVIEW   OF   THE   MECHANISM    OF    LABOR   IN   GENERAL. 

A  curious  fact  in  the  mechanism  of  labor,  and  one  which  has  claimed 
the  attention  of  all  modern  accoucheurs,  amongst  whom  we  may  mention 
especially  MM.  Dubois  and  Jacquemier,  is,  that  whatever  the  presentation 
may  be,  the  movements  undergone  by  the  foetus  during  its  expulsion  are 
always  the  same.  Finally,  Professor  Pajot  made  a  clear  statement  of  this 
single  mechanical  law,  and  applied  it  to  all  the  presentations.  "  AVe  main- 
tain," he  says,  "that  all  labors,  so  far  as  the  mechanical  phenomena  which 
they  present  are  concerned,  are  governed  by  the  same  law.  There  is, in  fact, 
but  one  mechanism  of  labor,  whatever  the  presentation  and  position  may  be,  pro- 
vided the  expulsion  takes  place  spontaneously,  that  is  to  say,  without  the 
intervention  of  art  and  at  term,  for  in  cases  of  abortion  the  expulsion  is  not 
of  the  regular  character."  (Pajot,  Dictionnaire  Ency  eloped  iuue  des  Science* 
Medicales.) 


372  LABOR. 

We  accept  fully  this  view  of  the  subject,  and  repeat  that  all  spontaneous 
labors  obey  the  same  law  as  respects  their  mechanism.  The  presenting  part 
of  the  fcetus  is  first  modified,  as  to  its  size  or  direction,  in  order  to  adopt  it 
to  the  opening  of  the  superior  strait ;  then  it  descends  into  the  cavity  of  the 
pelvis,  and  having  reached  the  inferior  strait  turns,  so  as  to  present  its 
longer  diameters  to  the  longer  diameters  of  the  pelvis,  and  not  until  it  has 
undergone  this  series  of  movements  is  the  vulva  cleared  and  the  expulsion 
complete. 

We  have  thought  that  the  transition  would  be  easier  from  this  simplicity 
of  facts  to  the  region  of  theory,  if  the  classification  of  the  different  stages 
of  labor  were  somewhat  modified.  Although  the  most  recent  classifications 
are  wonderfully  simplified,  they  still  fall  short  of  entire  uniformity,  present- 
ing here  and  there  some  omissions  and  a  few  contradictions.  For  instance, 
in  deliveries  by  the  vertex  or  face  five  stages  are  described,  the  first  four  of 
which  are  really  executed  by  the  head,  then  the  rotation  of  the  body  is 
described  as  the  fifth  and  last  time,  without  considering  its  final  expulsion, 
which  is  merely  mentioned.  The  disengagement  of  the  body  being  thus 
disregarded,  students  are  liable  to  forget  an  important  cause  of  dystocia 
described  by  Jacquemier,  viz.,  the  large  size  of  the  shoulders.  In  cases  of 
delivery  by  the  head,  a  fifth  stage,  that  of  rotation  of  the  body,  is  described, 
why,  therefore,  not  be  logical  throughout  and  admit  a  sixth  stage  for  its 
expulsion  ? 

In  breech  labors,  four  or  even  five  stages  are  commonly  described.  It  is 
well,  indeed,  to  recognize,  as  do  MM.  Dubois  and  Pajot,  a  first  stage  for  the 
diminution  in  size  and  modelling  of  the  presenting  part ;  then  the  engage- 
ment, rotation,  and  expulsion  of  the  body  will  correspond  with  the  second, 
third,  and  fourth  stages.  Up  to  this  point  there  is  entire  uniformity  between 
labors  by  the  head  and  breech,  but  for  the  fifth  stage  in  breech  cases  we 
have  a  confused  account  of  the  internal  rotation  of  the  head  and  its  final 
expulsion.  The  fifth  stage,  which  in  a  uniform  nomenclature  ought  to 
recall  similar  things,  would,  in  this  case,  seem  to  imply  a  notable  difference 
between  the  various  kinds  of  delivery ;  for,  in  the  same  stage  in  vertex 
presentations,  the  body  rotates  without  being  expelled,  whilst  in  breech  cases 
the  head  rotates  and  is  expelled  at  the  same  time.  In  order,  therefore,  to 
remove  this  apparent  difference,  it  were  better  to  divide  the  fifth  stage  of 
delivery  by  the  pelvis  into  two  stages,  the  fifth  for  the  internal  rotation  of 
the  head,  and  the  sixth  for  its  final  expulsion.  The  throwing  of  these  two 
stages  into  one,  is  essentially  the  same  as  confounding  the  third  and  fourth 
stages  of  delivery  by  the  vertex. 

In  order  to  remove  these  imperfections  and  contradictions  we  have,  there- 
fore, described  six  stages  in  the  mechanism  of  labor  in  each  of  the  presenta- 
tions ;  an  innovation  which  has  the  advantage  of  showing  clearly  that  this 
mechanism  is  uniform  throughout.  These  views  have  been  taught  in  our 
lectures,  in  the  text  of  the  Atlas  Complementaire  de  tons  les  Tra'des  d'Ac- 
couchements,  by  Lenoir,  and  one  of  our  students  has  made  it  the  subject  cf 
his  inaugural  thesis.     (Granier.     Theses  de  Paris,  1863,  No.  98.) 

For  the  clear  understanding  of  this  uniformity  of  the  general  laws  of  the 
mechanism  of  labor,  we  should  observe  in  the  first  place  that  the  fcetus, 


MECHANICAL     PHENOMENA     OF     LABOR.  373 

doubled  up  as  it  is  in  the  cavity  of  the  uterus,  with  its  limbs  pressed  closely 
against  the  chist,  and  the  neck  concealed  between  the  base  of  the  head  and 
the  upper  part  of  the  chest,  forms  really  but  two  distinct  parts,  the  head 
and  the  body.  Now  let  us  for  a  moment  imagine  these  two  parts  to  be  sepa- 
rate and  independent,  and  that  they  presented  themselves  one  after  the 
other ;  then  we  should  have  four  stages  for  the  expulsion  of  each.  The 
head  would  be  flexed,  engage,  rotate,  and  be  delivered ;  nor  would  this  suc- 
cession of  phenomena  be  in  any  respect  altered  whether  the  engagement  of 
the  head  should  precede  or  follow  that  of  the  body.  The  delivery  of  each 
of  these  two  parts  of  the  foetus  would  then  present  similar  phenomena  to 
the  observer;  nor  will  there  be  the  least  occasion  for  surprise,  when  we  con- 
sider that  the  section  of  each  presentation  gives  an  almost  oval  figure,  the 
longer  and  shorter  diameters  of  which  are  adapted  in  the  same  way  to  the 
curvature  and  form  of  the  genital  passages. 

Setting  hypotheses  aside,  if  we  examine  a  foetus  closely,  we  shall  be  at 
once  struck  with  the  fact  that  it  represents  two  superposed  masses,  the  head 
and  the  body  so  united  by  the  neck  that  one  cannot  progress  without  the 
other;  and  that  whilst  the  presenting  part  undergoes  its  four  movements 
of  compression,  engagement,  rotation,  and  disengagement,  the  remaining 
part  has  also  become  flexed  and  engaged,  in  other  words,  has  performed  its 
two  first  movements. 

On  the  other  hand,  we  observe,  whilst  examining  a  foetus,  that  the  long 
diameters  of  its  two  superposed  parts  (head  and  body)  have  opposite  direc- 
tions, from  before  backward  for  the  head,  and  transverse  for  the  bod  v. 
These  two  diameters  are  also  at  right  angles  to  each  other,  whence  it 
happens  that  when  one  of  the  two  parts  has  a  direction  adapted  to  its  ready 
exit  from  the  pelvis,  the  other  will  have  an  opposite  direction.  For  example, 
when  the  head  disengages  from  before  backward  at  the  vulva,  the  shoulders 
are  situated  transversely  at  the  inferior  strait;  which  renders  it  necessary 
that  the  head  and  body  should  perform  successively  the  same  mechanical 
movements  of  rotation  and  disengagement. 

If  we  note,  therefore,  such  mechanical  phenomena  only  as  are  apparent 
and  palpable,  such,  in  fact,  as  the  accoucheur  is  expected  to  detect  at  any 
moment,  we  shall  have  in  the  first  place  to  observe  successively  the  four 
motions  performed  by  the  part  which  engages  first,  and  next  the  final  move- 
ments of  rotation  and  expulsion  of  the  second  part  of  the  foetus. 

We  have  thus  to  describe  six  stages  in  the  delivery: 

1st  Stage Compression       ") 

2d    Stage Engagement       I  of  the  first  foetal  part. 

3d    Stage Rotation  J 

4th  Stage Disengagement  | 

5th  Stage Rotation  I  of  the  second  foetal  part. 

6th  Stage Expulsion  J 

In  the  following  table  are  recapitulated  the  six  stages  in  the  mechanism 
of  labor  for  all  the  presentations. 

TABLE  of  the  six  Stages  of  Labor  in  all  the  Presentations. 

1st  Stage.        L  ,-         ,        •     f°S  ^eIerteX !'-v""xi"" 

Adaptation  of   \  lukm6  Place  m  I  oi  »he  face by  extension. 

,,        '   '      ,   ,.      1    presentations     I  of  tin-  breech bv  folding. 

the  presentation        ^                                  .  ..      .     .  ,.-,.- 

r  of  the   body \>y  iolding. 


74 


LABOR. 


fof  the  vertex by  sliding, 
of  the  face by  sliding, 
of  the  breech Iiy  sliding. 

of  the  body by  sliding. 

occiput for  the  vertex. 

:ice. 
eech. 

a  shoulder for  the  body. 

of  the  vertex by  extension. 

ace  in  J  of  the  face by  flexion. 

ations    1  of  the  breech by  progression. 

of  the  body by  lateral  flexion. 


i  ~-   — j j    j 

0  ,    0.  fn   •      .  ,       fthe  occiput for  the  vt 

3d  Stage.  Bringing  under      fa      ^  f      ^    fa 

>tation  of  the-1,  the  arch  of  the-^       ,  .  . •      ,,     > 

\       ,  .  I  a   hip tor  the  br 

resentation.         pubis  , r  ,  .  «     ,,     , 


Rot 
P 


4th  Stage. 
Disengagement, 


J  Taking  pi 
\    presental 


C  a  shoulder in  cases  of  vertex  presentation 

Bringing  under  |  a  shoulder in  cases  of  face  presentation. 


5th  Stage. 

o  a  ion  o        e  |  ^  arcj,  0f  tne  j  tue  0CCipUt in  cases  of  breech  presentation. 

second  foetal     ■>  \    ■  „  .     ,    * 


part . 


6th  Stage. 
Final  expulsion. 


pubis 


By  disengage- 
ment 


the  occiput in  cases  of  body  presentatioii 

(spontaneous  evolution]. 

of  the  body  in  cases  of  vertex  presentation. 

of  the  body in  cases  of  face  presentation. 

of  the  head in  cases  of  breech  presentation. 

of  the  head in  cases  of  body  presentation 

(spontaneous  evolution). 

By  applying  this  general  classification  to  each  presentation  separately, 
we  obtain  entire  uniformity  for  the  mechanism  of  every  k.'nd  of  labor. 

VERTEX. 

1st  Stage Flexion  of  the  head. 

2d   Stage Engagement  of  the  head. 

3d  Stage Rotation  of  the  head. 

4th  Stage Disengagement  of  the  head. 

5th  Stage Internal  rotation  of  the  body. 

6th  Stage Expulsion  of  the  body. 

FACE. 

1st  Stage Extension  of  the  head. 

2d  Stage Engagement  of  the  head. 

3d  Stage Rotation  of  the  head. 

4th  Stage Disengagement  of  the  head. 

5th  Stage Internal  rotation  of  the  body. 

6th  Stage Expulsion  of  the  body. 

BREECH. 

1st  Stage Folding  of  the  breech. 

2d  Stage Engagement  of  the  breech. 

3d  Stage Rotation  of  the  breech. 

4th  Stage Disengagement  of  the  breech. 

5th  Stage Internal  rotation  of  the  head. 

6th  Stage Expulsion  of  the  head. 

BODY.      (Spontaneous  evolution.) 

1st  Stage Folding  of  the  body. 

2d  Stage Engagement  of  the  body. 

3d  Stage Rotation  of  the  body. 

4th  Stage Disengagement  of  the  body. 

5th  Stage Internal  rotation  of  the  head. 

6th  Stage Expulsion  of  the  head. 


TWIN    LABORS. 


375 


CHAPTER  IV. 


TWIN     LABORS. 


Although  the  expulsion  of  the  child  often  takes  place  in  twin  pregnancies 
with  as  much  facility  or  sometimes  even  with  greater  rapidity  than  in  ordi- 
nary labors,  yet  it  must  not  be  supposed  that  the  whole  duration  of  the 
labor  is  always  shorter;  for  very  often,  on  the  contrary,  the  parturition  will 
be  found  to  drag  along,  and  become  tedious.  Indeed,  by  reflecting  on  the 
circumstances  which  then  cornjdicate  the  process,  it  will  not  be  a  difficult 
matter  to  explain  this  unusual  delay,  since  it  is  well  known  that  an  exces- 
sive distention  of  the  womb  greatly  diminishes  both  the  force  and  frequency 
of  its  contractions ;  and,  as  the  labor  often  comes  on  before  the  end  of  the 
ninth  month,  the  cervix  uteri  has  not  yet  undergone  those  modifications 
which  usually  render  its  dilatation  at  term  quite  easy ;  besides  which,  the 
elevation  of  the  presenting  part,  whose  engagement  is  impeded  by  the  pre- 
sence of  the  second  foetus,  also  assists  in  retarding  this  dilatation.  The 
stage  of  expulsion,  which  the  small  size  of  the  twins  would  at  first  sight 
seem  to  facilitate,  is  often  delayed  by  the  feebleness  of  the  contractions,  and 
also  by  the  decomposition  and  considerable  loss  of  the  force  occasioned  by 
the  presence  of  an  ovum,  still  remaining  intact  within  the  cavity  of  the 
womb ;  and  such  is  the  unfavorable  influence  of  this  latter  circumstance, 
that  it  is  only  through  the  thickness  of  the  second  ovum  that  the  contrac- 
tions of  the  greater  part  of  the  uterine  fibres  can  possibly  reach  the  body 
of  the  child  that  first  presented  at  the  upper  strait.  But  when  the  first 
child  presents  by  the  pelvic  extremity,  the  escape  of  the  head  is  particu- 
larly apt  to  be  attended  with  difficulties;  for,  if  the  perineum  be  resistant, 
even  in  a  slight  degree,  as  in  priruiparae,  for  example,  the  intervention  of 
art  will  nearly  always  be  indispensable,  because  the  uterus,  being  wholly 
occupied  by  the  other  ovum,  can  have  no  further  influence  on  the  head  of 
the  first. 

The  following  table,  which  gives  the  presentation  of  both  children  in 
three  hundred  and  twenty-nine  cases  of  twin  pregnancy,  will  serve,  as  a 
matter  of  curiosity,  to  show  the  relative  frequency  of  the  positions. 


IN    329    TWIN    PREGNANCIES,    THE    TWO    CHILDREN    PRESENTED    AS    FOLLOWS  : 

Both  by  the  head. 
134  times. 

The  1st  by  the  head  ; 

the  2d  by  the  breech. 

55  times. 

Both  by  the  breech. 
12  times. 

The  1st  by  the  breech  : 

the  2d  by  the  head. 

31  times. 

The  1st  by  the  breech; 

the  2d  by  one  foot. 

11  times. 

Both  by  the  feet. 
8  times. 

The  1st  by  the  feet; 

the  2d  by  the  head. 

29  times. 

The  1st  by  the  breech  : 

the  2d  by  the  elbow. 

once. 

The  1st  by  the  head; 

the  2d  by  the  shoulder. 
7  times. 

The  1st  by  the  face  ; 

the  2d  by  the  head. 

once. 

The  1st  by  the  feet; 

the  2d  liy  one  hand. 

onee. 

The  1st  by  the  feet: 

the  2d  by  the  breech. 

once. 

Nearly  always  the  twins  present  one  after  the  other  at  the  superior  strait, 
and  the  expulsion  of  the  first  is  promptly  followed   by  the   birth  of  thf 


376  LABOR. 

second ;  and  the  same  is  true  of  the  others  when  there  ire  more  than  two 
But  it  occasionally  happens  that  the  labor  does  not  progress  so  regularly 
and  that  the  children  may  be  born  at  a  considerable  interval  from  each 
other,  and  their  expulsion  rendered  difficult  by  the  attendant  delays  and 
dangers.  It  most  generally  happens  that  the  womb,  being  fatigued  by  the 
efforts  necessary  for  the  expulsion  of  the  first-born,  retracts  a  little  after  this 
partial  depletion,  and  remains  in  a  state  of  rest  for  some  minutes,  in  conse- 
quence of  having  lost  a  part  of  its  contractile  properties ;  still  retaining, 
however,  a  greater  volume  than  usual.  By  placing  the  hand  on  the  ante- 
rior abdominal  region,  the  accoucheur  will  be  able  to  verify  the  abnormal 
size  of  the  organ,  and  to  detect,  through  this  wall,  the  inequalities  apper- 
taining to  the  foetus ;  besides,  another  amniotic  pouch,  or  the  presenting 
part  of  a  second  child,  can  readily  be  detected  at  the  upper  part  of  the 
uterine  neck  by  the  vaginal  touch.  In  general,  the  repose  of  the  womb  is 
but  momentary,  and  in  about  a  quarter  of  an  hour,  sometimes  at  the  end 
of  five  or  ten  minutes,  though  rarely  later  than  twenty  or  thirty  minutes, 
the  patient,  feels  the  pains  coming  on  again  ;  at  first  feeble  and  slow,  but 
soon  becoming  stronger  and  more  energetic.  Care  should  be  taken  to  rup- 
ture the  membranes,  if  this  had  not  already  occurred,  and  then  to  abandon 
the  rest  of  the  labor  to  the  powers  of  nature.  This  second  delivery  is  soon 
over,  as  a  general  rule,  when  the  foetus  presents  in  a  natural  position,  for 
the  parts  have  been  so  enlarged  by  the  passage  of  the  first  child,  that  they 
offer  but  little  resistance  to  the  escape  of  the  second.  But  in  some  cases, 
the  pains  which  have  been  suspended  after  the  birth  of  one  of  the  twins 
do  not  reappear  for  some  hours,  and  sometimes  even  not  for  several  days.1 

Now,  what  is  to  be  done  in  cases  of  this  kind  ? 

"  When  the  two  children  present  well,  and  the  expulsion  of  the  first  is 
effected  naturally,  and  without  great  fatigue  to  the  woman,  I  wait,"  says 
Merriman,  "until  the  pains  of  the  second  childbirth  come  on;  ordinarily, 
this  happens  shortly  after  the  escape  of  the  first-born.  If  efficacious  pains 
do  not  occur  in  the  course  of  a  quarter  or  half  an  hour,  I  provoke  the  con- 
traction by  rubbing  the  abdominal  tumor  gently  with  the  hand,  and  by 
titillating  the  os  uteri  with  the  finger ;  if  these  irritations,  made  simul- 
taneously on  the  body  and  neck,  are  ineffectual,  and  several  hours  elapse 
without  the  womb  contracting,  I  deem  it  advisable  to  excite  the  contractions, 
by  rupturing  the  membranes,  after  having  previously  administered  the  ergot. 
This  course  is  based  on  the  two  following  reasons :  where  we  have  delayed 
too  long  a  time,  the  pains  have  always  appeared  to  me  more  severe  than 
they  would  have  been  if  the  action  of  the  uterus  had  been  solicited  sooner  ; 
and  the  expulsion  of  the  second  child  has  commonly  seemed  to  me  more 
easy  through  the  parts  recently  dilated  by  the  first  delivery." 

1  Four  women,  registered  in  the  Dublin  Hospital,  were  delayed  ten  hours  in  the 
delivery  of  their  second  child.  The  reader  will  also  find,  in  the  Medical  and  Physical 
Journal  (April,  1811),  the  details  of  a  case  in  which  the  second  child  was  not  born  until 
fourteen  'lays  after  the  firs!  :  and  the  author  of  thai  communication  states,  that  another 
case  had  come  to  his  knowledge,  in  which  six  weeks  had  elapsed  between  the  birth  of 
the  twins.  A  woman  was  delivered  mi  the  4th  of  March,  181  I.  of  two  children:  she 
found  herself  so  well  on  t lie  second  day  that  *he  rose  to  attend  to  her  affairs,  but,  on 
the  sixth,  she  was  again  delivered  of  two  more.      (Gentleman's  Magazine,  1814.) 


PREMATURE    AND    RETARDED    LABORS.  377 

In  all  such  cases,  our  rules  of  conduct  should  be  based  on  the  condition 
of  the  womb  itself,  rather  than  on  the  length  of  time  that  may  have  elapsed 
since  the  birth  of  the  first  child ;  because  it  must  be  evident  that  relaxation 
and  inertia  of  this  organ  would  forbid  all  attempts  at  extraction,  and  that 
we  should  never  endeavor  to  deliver  the  second  child  before  having  excited 
the  organic  contractility  of  the  uterus,  by  all  the  available  means.  If,  by 
chance,  these  measures  prove  inadequate,  it  will  be  better  to  wait  several 
hours,  or,  if  necessary,  even  for  several  days,  rather  than  expose  her  to  the 
terrible  consequences  resulting  from  inertia. 

[The  presentation  and  position  of  each  child  in  twin  labors  are  detected  by  the 
same  signs  as  when  one  child  only  is  present,  observing,  however,  that  it  is  neces- 
sary to  be  careful  in  respect  to  the  data  supplied  by  palpation  and  percussion,  for 
the  presence  of  two  children  in  the  womb  alters  greatly  the  results  afforded  by  the 
former;  so  that  although  these  measures  may  sometimes  prove  helpful,  they  may 
also  very  easily  lead  into  error. 

That  auscultation  is  equally  unreliable  and  may  be  deceptive,  will  be  understood 
from  the  fact  that  the  idea  of  the  position  of  the  first  child  may  be  formed  from  the 
maximum  intensity  of  the  cardiac  pulsation  of  the  one  which  is  born  last. 

What  has  been  already  said  in  regard  to  the  touch,  will  suffice  for  twin  cases 
also,  although  difficulty  may  arise  from  the  simultaneous  engagement  of  both  chil- 
dren—  for  which  case  we  refer  to  the  subject  of  dystocia.      (See  Dystocia.) 

The  expulsion  of  each  child  is  subject  to  the  usual  laws  which  govern  the 
mechanism  of  labor  as  already  described,  so  that  we  have  only  to  add  that  as  twins 
are  often  small  and  born  prematurely,  the  inequalities  in  the  mechanism  of  labor 
are  more  common,  especially  as  regards  the  second  child,  which  traverses  the  genital 
passages  which  have  been  enlarged  by  the  first  one.  In  short,  we  have  only  tc 
regard  a  twin  labor  as  two  successive  deliveries.] 


CHAPTER  V. 

OF    PREMATURE    AND    RETARDED    LABORS. 

ARTICLE   I. 

OF    PREMATURE   LABOR. 

When  a  woman  is  delivered  in  the  seventh  or  eighth  month  of  her  gesta- 
tion, the  labor  is  said  to  be  premature.  Now  a  great  number  of  causes  may 
determine  the  expulsion  of  the  child,  before  the  ordinary  term  of  its  intra- 
uterine life;  such,  for  instance,  as  an  excessive  distention  of  the  womb,  whether 
this  be  occasioned  by  too  great  a  quantity  of  the  amniotic  liquid,  by  hydror- 
rhea, or  by  the  presence  of  two  or  more  infants  in  the  uterine  cavity ;  the 
accidental  death  of  the  foetus;  the  artificial  evacuation  of  the  liquor  amnii ; 
any  violent  muscular  effort ;  the  abuse  of  strong  purgatives;  various  acute 
diseases,  more  especially  those  of  the  skin;  and  certain  conditions  of  the 
animal  economy,  as  plethora,  great  debility,  or  an  excessive  irritability  and 
sensibility.  Finally,  in  a  singular  case  already  mentioned,  premature  labor 
occurred  eight  times  consecutively,  in  consequence  of  extreme  itching  of  the 

Surface. 


378  LABOR. 

Delivery  before  term  is  said  to  be  often  preceded  by  a  severe  chill 
Burns  supposes  that  this  chill  occurs  Immediately  before  or  after  the  death 
of  the  foetus.    I  have  no  recollection  of  having  observed  anything  of  the  kind 

In  some  cases,  the  uterus  is  fully  developed  prior  to  the  ordinary  term  of 
gestation,  and  then  the  contraction  commences  and  goes  on  as  regularly  as 
usual ;  but  in  most  instances,  the  organ  has  not  as  yet  undergone  all  the 
necessary  modifications  for  the  proper  accomplishment  of  labor,  and  the 
'atter,  consequently,  exhibits  numerous  irregularities  in  its  course.  The 
uterine  neck  and  orifice  are  not  yet  properly  effaced  and  softened.  For 
example,  it  is  not  at  all  uncommon  to  find  the  neck  sufficiently  dilated, 
during  the  primary  pains,  to  permit  the  introduction  of  the  finger,  and  this 
notwithstanding  the  lips  are  still  thick  and  of  a  considerable  length.  This 
length  of  neck  must  greatly  retard  the  dilatation,  for  the  latter  cannot  really 
commence  until  after  the  effacement  is  completed,  which  often  proves  a 
tedious  process. 

This  first,  or  preparatory,  stage  is  marked  by  pains  that  are  very  irregular 
both  in  their  duration  and  intensity,  accompanied  by  a  feverish  state ;  the 
patient  experiences  a  very  distressing  sensation  of  weight  about  the  belly, 
and  she  is  usually  restless  and  agitated.  When  the  cervix  is  once  effaced, 
the  os  uteri  begins  to  dilate;  but  this  dilatation  is  much  slower  than  at  term, 
because  the  neck  has  not  yet  attained  the  same  degree  of  softening,  and 
therefore  offers  more  resistance  to  the  contractions  of  the  body. 

But,  although  the  first  stage  is  somewhat  longer,  the  second,  or  that 
wherein  the  expulsion  occurs,  is  generally  shorter  than  in  labor  at  term, 
owing  to  the  small  size  of  the  child  ;  nevertheless,  this  advantage  is  often 
counterbalanced  by  the  irregularity  and  the  spasmodic  nature  of  the  con- 
tractions, which  are  then  more  apt  to  assume  this  form  than  under  ordinary 
conditions.  For,  as  the  muscular  organization  of  the  uterus  is  not  yet  com- 
plete, we  can  understand  why  its  contractile  powers  are  less  perfect;  and 
also,  on  the  other  hand,  how  the  morbid  cause  which  has  developed  a 
premature  action  in  it  must  necessarily  influence  the  regularity  of  their 
contractions. 

The  vertex  presentations  are  far  from  being  so  frequent  here  as  in  the 
natural  labor  at  term,  and  those  of  the  breech,  according  to  M.  P.  Dubois, 
are  proportionally  more  common  as  the  labor  is  more  premature.  For 
instance,  in  ninety-six  still-born  children,  delivered  during  the  last  two 
months  of  gestation  at  the  hospital  of  La  Maternity  seventy-two  presented 
by  t he  head,  twenty-two  by  the  pelvic  extremity,  and  two  by  the  shoulder; 
whilst  in  seventy-three  living  children,  who  had  only  reached  the  seventh 
month  of  intra-uterine  life,  sixty-one  presented  the  head,  ten  only  the  breech, 
and  two  the  shoulder.  Hence,  it  is  evident  that  the  number  of  pelvic  pre- 
sentations in  premature  parturitions  is  comparatively  greater  where  the 
children  are  born  dead,  ami  also  that,  when  the  iVetuses  are  living,  the 
podalic  extremity  presents  first  much  oftener  than  in  ordinary  labors. 

Finally,  according  to  Burns,  women  who  are  taken  in  labor  before  term 
are  more  exposed  than  others  to  hemorrhages  during  its  progress,  and  the 
delivery  of  the  after-birth  is  both  more  difficult  and  more  liable  to  accident 
than  usual. 


PREMATURE     AND     RETARDED     LABORS.  379 

"  When  a  wcman  is  threatened  with  premature  labor,"  continued  the 
author  just  named,  "  we  ought,  unless  we  are  sure  of  the  death  of  the  child, 
to  endeavor  to  check  the  process,  which  is  done  by  keeping  the  patient  cool 
and  tranquil  in  the  horizontal  position,  bleeding  her  in  the  arm  if  she  be 
plethoric,  or  the  pulse  be  throbbing;  but  above  all,  by  administering  opiate 
injections  immediately  (forty  to  sixty  drops  of  Sydenham's  laudanum,  in 
two  or  three  doses,  in  the  course  of  a  couple  of  hours)." 

When  the  labor  is  once  established,  it  is  to  be  conducted  much  in  the 
same  way  with  parturition  at  the  full  time ;  nevertheless,  says  Burns,  the 
following  observations  should  be  carefully  attended  to:  1.  The  patient  must 
avoid  much  motion,  lest  a  hemorrhage  be  excited ;  2.  Frequent  examina- 
tions are  hurtful  by  retarding  the  process,  and  tending  to  produce  spas- 
modic contraction  ;  and,  if  this  takes  place,  a  full  dose  of  the  tincture  of 
opium  should  be  given  at  once;  3.  A  rigid  state  of  the  os  uteri  requires 
venesection  to  a  moderate  extent ;  4.  The  delivery  of  the  child  is  to  be  re- 
tarded rather  than  accelerated  in  the  last  stage,  in  order  that  the  uterus 
may  have  time  to  contract  on  the  placenta ;  5.  This  is  to  be  further  assisted 
by  rubbing  and  gently  pressing  on  the  uterine  region  after  the  child  is 
born ;  6.  The  delivery  of  the  after-birth  requires  more  than  ordinary  care 
(see  Delivery  of  the  After-birth)  :  thus,  we  are  not  to  pull  on  the  cord,  for  it 
is  easily  broken ;  besides,  it  is  often  necessary  to  introduce  the  hand  in  the 
uterus  to  aid  the  detachment  of  the  placenta  artificially,  and  to  prevent  its 
being  retained  by  the  irregular  contractions ;  and  lastly,  great  attention  is 
to  be  paid  to  the  patient  herself  for  some  days  after  the  delivery,  for  it  has 
justly  been  observed  that  she  is,  from  the  mere  fact  of  having  had  a  prema- 
ture labor,  more  exposed  than  others  to  those  inflammatory  affections  which 
so  often  complicate  the  parturient  state.  With  regard  to  the  premature 
labors  brought  on  by  the  accoucheur  we  shall  say  nothing  at  present,  as 
we  shall  have  to  treat  of  them  more  particularly  under  the  head  of  Opera- 
tions. 

ARTICLE  II. 

OF   RETARDED    LABOR. 

As  an  ordinary  rule,  the  pregnancy  terminates  about  the  two  hundred 
and  seventieth  day  after  conception.  However,  labor  often  occurs  at  an 
earlier  period  than  this,  and,  on  the  other  hand,  it  may  not  appear  until 
some  time  in  the  course  of  the  tenth  month,  or  even  at  the  termination  of 
this  period,  although  the  latter  is  a  much  more  unusual  circumstance.  In 
making  this  statement,  we  decide  a  question  in  advance  that  gave  rise  to 
some  very  sharp  and  animated  discussions  during  the  last  century;  and, 
still  more  recently,  the  tribunals  of  England  have  summoned  to  their  bar 
the  most  celebrated  physicians  of  Great  Britain,  and  have  listened  to  nume- 
rous and  protracted  pleadings  for  and  against  the  legitimacy  of  retarded 
labors. 

But  this  question  no  longer  presents  to  the  medical  jurist  the  same  diffi- 
culty that  it  did  in  the  past  century,  for  the  French  law  has  now  declared 
every  child  to  be  legitimate  that  is  burn  alter  the  one  hundred  and  eightieth 


380  LABOR. 

or  before  the  three  hundredth  day  of  marriage ;  and,  as  if  it  were  possible, 
in  the  eye  of  the  law,  for  a  pregnancy  to  continue  more  than  ten  months, 
it  further  adds  that  the  legitimacy  of  a  child  born  three  hundred  days  after 
tl  e  dissolution  of  the  marriage  contract  may  be  contested. 

Although  a  legal  decision  has  thus  deprived  the  question  of  retarded 
labors  of  its  greatest  interest,  yet  we,  as  practitioners,  may  be  permitted  to 
recall  briefly  the  principal  reasons  that  militate  in  their  favor. 

At  first,  it  was  very  natural  to  study  the  process  in  those  animals  which 
approach  the  nearest  to  man  in  this  respect,  in  order  to  judge  of  the  possi- 
bility of  a  retarded  birth  in  the  human  species. 

Among  the  numerous  observations  made  on  this  subject,  those  submitted 
by  M.  Tessier,  in  1819,  to  the  Academy  of  Sciences  at  Paris,  of  which  the 
following  is  a  summary,  are  probably  the  most  exact,  namely:  out  of  one 
hundred  and  seventy-one  cows,  fourteen  calved  from  the  two  hundred  and 
forty-first  to  the  two  hundred  and  sixty-sixth  day  :  three  on  the  two  hun- 
dred and  seventieth ;  fifty,  from  the  two  hundred  and  seventieth  to  the  two 
hundred  and  eightieth ;  sixty-eight,  from  the  two  hundred  and  eightieth  to 
the  two  hundred  and  ninetieth  ;  and  five,  on  the  three  hundred  and  eighth 
day,  which  gives  a  difference  of  sixty-seven  days  between  the  births,  if  we 
compare  the  shortest  with  the  longest  period.  Of  one  hundred  and  two 
mares : 


3  foa 

led  on  the 

31 1th  day. 

1 

'         " 

314th     " 

1       ' 

C                  (t 

325th     " 

1 

(             n 

326th     " 

2       ' 

i 

330th     " 

47       ' 

'    from  the 

340th  to  the  350th  day. 

25       « 

C                  tt 

350th     •'        360th     " 

21 

< 

360th     "        377th     " 

1       ' 

'     on  the 

394th  day. 

102 

Making  a  difference  of  eighty-three  days  between  the  two  extremes.  Nine 
months  and  ten  days  being  the  average  term  for  cows,  and  eleven  months 
and  ten  days  for  mares. 

These  well-ascertained  variations  in  the  terms  of  gestation  in  animals, 
certainly  afforded  a  strong  presumption  of  their  existence  in  the  human 
species  also  ;  for  if  cows  and  mares,  whose  gestations  are  not  disturbed  by 
the  various  causes  that  may  lead  to  changes  in  a  woman,  may  thus  defer 
for  some  time  the  ordinary  period,  how  much  more  would  human  females. 
who  are  subject  to  so  many  diseases,  and  upon  whom  the  moral  and  social 
relations  exert  so  powerful  an  influence, — how  much  more  likely  would 
they  be  to  exhibit  numerous  varieties  in  the  duration  of  their  pregnancies? 

But  all  this  was  a  mere  probability;  and  the  question  would  still  remain 
undetermined,  if  careful  observations  directly  made,  and  well  made  on  the 
human  species,  had  not  removed  all  doubts  on  that  point ;  for  several  cases 
bearing  on  this  subject  now  enrich  our  science,  where  a  single  well-estab- 
lished instance  would  suffice  to  produce  conviction.  Take,  for  example,  the 
following  case,  reported  by  Desormeaux :  A  lady,  the  mother  of  three  chil 
dren,  became  affected  with  insanity,  for  which  all  the  resources  of  thera- 


DELIVERY     OF     THE     AFTER-BIRTH.  381 

peutics  were  tried  in  vain.  As  her  physician  thought  that  another  preg- 
nancy might  possibly  re-establish  her  intellectual  faculties,  the  husband 
consented  to  note  on  a  register  the  time  of  each  sexual  union,  which  only 
took  place  every  three  months,  lest  a  previous  conception  (then  uncertain; 
should  be  disturbed.  Now,  this  lady,  who  was  closely  watched  by  her 
domestics,  and  was  besides  endowed  with  the  most  rigid  principles  of  reli- 
gion and  morality,  was  not  delivered  before  the  expiration  of  nine  months 
and  a  half. 

Merriman  furnishes  a  summary  of  one  hundred  and  fifty  gestations,  in 
each  of  which  he  has  noted  the  precise  day  of  the. last  appearance  of  the 
menses.     From  this  table  it  appears  that — 

5  women  were  delivered  in  the  37th  week  —  t.  e.  from  252  to  259  days. 

16       ■'  "  "  38th  "  "  262  to  266  " 

21        '«  »  "  39th  "  "  267  to  273  " 

46       "  "  "  40th  "  "  274  to  280'  " 

28       "  "  "  41st  "  «  281  to  287  " 

18  "  "  42d  "  "  288  to  294  " 

11"  •'  "  43d  "  "  295  to  301  " 

5       "  "  "  44th  "  "  303  to  306  " 

1 50 

The  foregoing  statement  exhibits  the  great  variety  in  the  length  of  gesta- 
tion. There  is,  in  fact,  a  difference  of  fifty-six  days  between  the  two 
extremes ;  and,  supposing  that  each  woman  became  pregnant  five  days 
before  the  return  of  her  courses,  five  of  them,  at  least,  would  overrun  the 
average  term  of  nine  months  by  ten  or  twelve  days. 


CHAPTER   VI. 

OF  THE   DELIVERY   OF   THE    AFTER-BIRTH. 

This  comprises  the  natural  or  artificial  expulsion  of  the  fcetal  append- 
ages from  the  mother's  womb,  and  is  the  complement  of  the  labor.  Like 
the  latter,  it  is  generally  accomplished  by  the  unaided  powers  of  nature, 
though  in  certain  cases,  which  are  fortunately  very  rare  (about  one  in  two 
hundred),  it  is  attended  by  difficulties  or  complicated  by  accidents  that  may 
require  the  intervention  of  art.  We  shall,  therefore,  have  to  treat  of  the 
natural  and  the  artificial  delivery  of  the  after-birth,  the  former  of  which, 
only  will  be  described  in  this  place  and  the  latter  included  in  the  article 
Dystocio. 

Whilst  the  expulsion  of  the  foetus  is  being  completed  by  the  spontaneous 
exit  of  the  breech  and  lower  extremities,  or  immediately  after  the  expulsion, 
the  walls  of  *he  uterus  retract  in  virtue  of  their  inherent  contractility  of 
tissue,  and  its  cavity  diminishes  ;  but  the  placenta,  being  a  spongy  and  non- 
contractile  mass,  does  not  follow  this  action  of  the  organ.  Consequently, 
it  becomes  puckered  up,  and  the  cellular  and  vascular  tissues,  that  connect 
it  to  the  internal   uterine  surface,  are  rendered  tense  and  then  torn,  as  the 


382  LABOR. 

difference  in  the  respective  size  of  the  two  bodies  becomes  greater  under  the 
force  of  the  repeated  contractions.  A  rupture  of  all  these  bonds  of  union 
is  soon  effected,  the  placenta  is  completely  detached  and  forced  down  upon 
the  os  uteri ;  the  latter,  being  irritated  by  its  presence,  reacts  on  the  body 
of  the  organ  which  is  immediately  thrown  into  contraction;  the  internal 
orifice,  which  was  closed  after  the  delivery  of  the  child,  again  dilates,  and 
the  placenta,  being  driven  from*  the  uterine  cavity,  passes  into  the  vagina, 
whence  it  is  forced  outwards  by  the  contraction  of  the  vaginal  walls  aided 
by  the  abdominal  muscles. 

Hence  there  are  three  distinct  stages  in  the  delivery  of  the  after-birth ; 
which  we  may  divide,  like  Desormeaux,  into  the  detachment  of  the  placenta, 
its  expulsion  from  the  uterus,  and  its  expulsion  from  the  vagina. 

The  detachment  of  the  placenta  is  not  always  accomplished  in  the  same 
way ;  the  process  varying  with  the  part  of  the  uterus  to  which  it  is  united. 
For  instance,  when  attached  to  the  fundus,  the  separation  first  begins  near 
the  centre  of  the  mass,  because  this  is  the  thickest  part,  and  can  least 
accommodate  itself  to  the  retraction  of  the  uterine  walls  ;  whilst  its  thinner 
margins,  being  more  easily  wrinkled,  are  less  liable  to  rupture  the  tissue 
connecting  them  with  the  womb ;  a  lenticular  cavity  is  thereby  created, 
which  is  bounded  externally  by  the  still  adherent  borders  of  the  placenta. 
A  quantity  of  blood  is  gradually  effused  into  this  cavity,  which  contributes, 
with  the  uterine  contractions,  to  effect  the  separation ;  thus,  in  this  case, 
the  detachment  is  effected  from  the  centre  towards  the  circumference.  The 
placenta,  being  wholly  detached,  then  descends  to  the  orifice,  its  foetal  sur- 
face corresponding  to  the  latter,  and  becoming  the  external  face,  whilst  the 
uterine  surface  is  the  internal  face,  which,  together  with  the  inverted  mem- 
branes, constitutes  a  pouch,  wherein  such  a  quantity  of  fluid  or  coagulated 
blood  is  occasionally  collected,  as  to  seriously  impede  its  delivery. 

When  it  is  attached  to  the  anterior,  the  posterior,  or  the  lateral  portion 
of  the  womb,  the  separation  commences  at  one  of  the  margins  ;  or,  if  at  the 
centre,  it  is  soon  propagated  towards  one  border,  generally  the  superior, 
though,  in  some  instances,  the  inferior  one.  In  the  former  case,  the  process 
advances  in  the  way  just  described,  and  the  placenta  again  presents,  by  its 
foetal  surface,  at  the  cervix  uteri;  but,  in  the  latter,  being  suspended  on  the 
uterine  wall  until  the  detachment  is  completed,  it  presents  at  the  neck  by 
its  inferior  margin.  It  is  then  generally  folded  upon  itself,  and  engages  in 
the  orifice  rolled  up  in  a  conical  form. 

When  the  placenta  presents  its  fcetal  surface  at  the  os  uteri,  it  plugs  up 
the  orifice  by  its  bulk,  and  prevents  the  blood  from  escaping ;  wherefore, 
its  delivery  in  such  cases  is  usually  followed  by  the  expulsion  of  numerous 
large  coagula.  But  where  only  one  border  engages,  there  is  no  obstacle  to 
the  issue  of  the  blood,  and  hence  the  discharge  of  this  fluid  commences  with 
I  he  detachment  of  the  after-birth,  is  increased  at  every  pain,  and  persists 
throughout  the  whole  process. 

From  the  description  just  given,  the  reader  would  naturally  suppose  that 
the  detachment  of  the  placenta  only  begins  after  the  child  is  born;  this, 
however,  is  not  always  the  case.  In  fact,  the  following  phenomena  are  more 
usually  observed  to  take  place:  as  soon   as   the  labor-pains  are  developed 


DELIVERY    OF    THE    AFTER-BIRTH.  383 

and  the  dilatation  of  the  os  uteri  has  commenced,  the  separation  of  the 
ovum  hegins  in  the  neighborhood  of  the  uterine  orifice,  and  then  gradually 
progresses  over  all  parts  of  its  surface,  although  not  in  a  perfect  and  com- 
plete manner.  After  the  membranes  are  ruptured,  and  the  waters  are 
partially  discharged,  the  uterine  cavity  diminishes ;  the  ovum  becomes 
wrinkled,  and  its  detachment  is  carried  to  a  still  greater  extent;  even 
involving  the  after-birth,  as  proved  by  the  fact  that  the  fluid  or  coagulated 
blood  is  frequently  expelled  simultaneously  with  the  foetus,  in  cases  of  pro- 
tracted labor ;  which  blood  must  evidently  come  from  that  portion  of  the 
uterine  surface  in  contact  with  the  placenta.  A  separation  of  the  greater 
part  of  the  placental  mass  is  particularly  apt  to  occur  in  the  breech  pre- 
sentations in  consequence  of  the  gradual  contraction  of  the  womb,  a.s  the 
lower  parts  of  the  foetus  are  delivered. 

The  interval  between  the  child's  birth  and  the  delivery  of  the  secundines 
is  very  variable.  Dr.  Clarke,  from  a  great  number  of  observations,  estab- 
lished its  mean  duration  at  twenty-five  minutes ;  but  if  by  this  a  perfectly 
spontaneous  delivery  is  to  be  understood,  one  in  which  no  traction  is  made  on 
the  cord,  we  believe  he  is  in  error,  for  this  interval  is  generally  much  longer. 
At  the  instance  of  M.  P.  Dubois,  we  made  some  experiments,  in  1836,  with 
a  view  of  determining  this  question  ;  and  those  researches  proved  that,  when 
the  delivery  was  left  entirely  to  nature,  the  final  expulsion  of  the  placenta 
did  not  usually  occur  under  an  hour  or  an  hour  and  a  half  after  the  birth 
of  the  child.  It  is  true,  the  detachment  of  the  after-birth,  and  its  removal 
from  the  uterine  cavity,  is  effected,  as  Clarke  states,  in  the  course  of  fifteen, 
twenty,  or  twenty-five  minutes  ;  but,  having  passed  into  the  vagina,  it  some- 
times remains  there  for  several  hours  without  causing  the  least  irritation  by 
its  presence,  the  least  tenesmus,  or  bearing-down  effort.  This  circumstance 
is  easily  explained  by  the  fact  that  the  sensibility  of  the  vaginal  walls  is 
blunted,  as  it  were,  by  the  long  pressure  they  were  subjected  to  from  the 
head  and  other  parts  of  the  child.  Besides  which,  as  Levret  long  since 
remarked,  the  after-birth  will  be  the  sooner  expelled  in  proportion  as  the 
patient  is  stronger,  and  the  contractions  more  energetic ;  as  the  quantity  of 
water  in  the  womb  was  smaller,  and  as  the  period  between  the  rupture  of 
the  membranes  and  the  delivery  of  the  child  was  the  longer. 

Although  its  delivery  may  generally  be  left  to  the  powers  of  nature  with- 
out any  serious  inconvenience,  yet  it  is  equally  true  that  it  will  be  delayed 
a  long  time  in  a  large  number  of  cases.  Now,  such  a  delay  would  force 
the  patient  to  remain  on  a  bed,  which  is  poorly  adapted  for  repose  after  all 
the  fatigues  of  labor ;  and  besides,  so  long  as  the  delivery  is  not  completed, 
she  still  considers  herself  exposed  to  numerous  dangers,  and  her  fears  may 
have  an  unfavorable  influence  over  her  condition.  On  this  account,  most 
of  the  accoucheurs  of  the  present  day  believe  it  advisable  to  accelerate  the 
extraction  a  little,  for  the  purpose  of  relieving  the  woman  from  her  anxiety, 
and  of  sparing  her  unnecessary  pain  ;  without,  however,  attempting  to 
deliver  the  secundines  immediaiehj  after  the  child's  birth.  But,  before 
making  any  traction  on  the  umbilical  cord,  it  is  necessary  to  ascertain  the 
situation  of  the  placenta,  and  especially  the  condition  of  the  uterus.  If  the 
latter  is  small,  hard,  and  contracted,  and  situated  in  the  lowest  part  of  the 


38-i  LABOR. 

abdomen,  it  is  infinitely  probable  that  the  placenta  is.  in  great  part  at  leasi, 
expelled  from  the  cavity  of  the  womb  into  the  vagina.  This,  however,  may 
be  easily  ascertained,  for  the  finger  introduced  into  the  vagina  readily 
detects  the  mass,  and  even  distinguishes  the  insertions  of  the  cord.  There 
is  then,  generally,  nothing  to  prevent  its  being  extracted  at  once,  and  simple 
tractions  upon  the  external  end  of  the  cord  are  all  that  are  required  for 
this  purpose. 

"When,  on  the  contrary,  the  uterine  tumor  continues  on  a  level  with,  or 
even  above  the  umbilicus,  and  has  a  soft  doughy  feel,  due  to  its  imperfect 
contraction,  the  placenta  is  very  probably  still  within  the  womb,  and  the 
first  object  should  be  to  ascertain  whether  or  not  it  is  detached.  Now  we 
know  that  the  separation  is  usually  accomplished  by  the  fresh  contractions 
that  reappear  after  the  apathy  which  follows  the  expulsion  of  the  child  ; 
and  hence,  there  is  every  reason  to  suppose  it  is  completed  when  these  con- 
tractions have  repeatedly  occurred.  A  little  blood  usually  escapes  from 
the  vulva  during  the  process.  Finally,  if  one  or  several  fingers  be  passed 
up  to  the  uterine  orifice,  the  after-birth  is  found  presenting  there,  and,  if  it 
should  not  be  met  with,  the  accoucheur  may  rest  satisfied  that  the  separa- 
tion is  not  yet  completed,  and  therefore  he  ought  to  wait.  Should  the 
detachment  be  delayed  too  long,  frictions  over  the  fundus  uteri  are  resorted 
to,  for  the  purpose  of  rousing  the  pains,  or  the  same  object  is  produced  by 
titillating  the  cervix  uteri  with  one  or  two  fingers.  Great  care  should  be 
:,dken  not  to  make  frequent  tractions  upon  the  cord,  for  unpleasant  conse- 
quences might  result.  Thus,  if  the  placenta  is  completely  adherent,  the 
tractions  are  liable  to  detach  a  part,  and  give  rise  to  hemorrhage,  or  they 
might  tear  away  a  portion  of  the  after-birth  and  leave  the  remainder  in  the 
womb  ;  again,  the  organ  might  be  inverted  or  the  cord  ruptured  thereby. 

Certain  writers  recommend  a  ligature  on  the  placental  extremity  of  the 
cord  after  the  child's  birth,  for  the  sole  purpose  of  facilitating  the  detach- 
ment of  the  after-birth.  The  easy  separation  when  this  has  been  done,  says 
M.  Stoltz,  is  caused  by  the  weight  and  turgescence  of  this  organ,  which, 
when  expelled,  is  found  to  be  engorged  with  blood ;  this  practice  is  attended 
with  no  inconvenience,  and  is  at  least  beneficial  by  preventing  the  patient's 
bed  from  being  soiled  with  the  blood  that  ordinarily  escapes  from  the  cord. 

After  its  entire  separation,  the  after-birth  constitutes  a  foreign  body  in 
the  uterine  cavity,  which  the  organ  endeavors  to  dislodge  by  contracting. 
These  contractions,  Avhich  are  recognizable  by  the  hardness  of  the  uterine 
globe,  and  which  are  usually  perceptible  to  the  patient,  indicate  the  time 
for  operating ;  the  accoucheur  then  takes  hold  of  the  umbilical  cord,  after 
having  enveloped  it  with  a  cloth  so  as  to  prevent  it  from  slipping,  and 
winds  its  end  around  one  or  two  fingers;  he  next  makes  a  moderate  trac- 
tion with  a  view  of  extracting  it,  but,  as  soon  as  any  resistance  is  felt,  he 
ought  to  slip  up  two  or  even  three  fingers  of  the  other  hand  along  the  upper 
surface  of  the  cord  as  far  as  the  os  uteri;  the  points  of  these  fingers,  which 
are  intended  to  press  the  cord  backwards,  are  brought  together  so  as  to 
receive  the  latter  in  the  entering  angle  thereby  formed,  around  which  it 
plays  like  a  pulley.  To  understand  the  advantage  of  this  manoeuvre,  it  is 
Dnly  necessary  to  bear  in  mind  that  the  tractions  made  by  one  hand  alone 


DELIVERY     OF     THE    AFTER-BIRTH.  385 

would  correspond  to  the  axis  of  the  vagina,  which  forms  an  angle  with  that 
of  the  uterus;  whence  it  happens  that  the  placenta,  instead  of  being  drawn 
towards  the  centre  of  the  orifice  it  has  to  traverse,  would  abut  against  its 
anterior  border,  and  the  corresponding  parts  of  the  cervix,  upon  which  all 
the  tractive  efforts  are  spent.  The  patient  should  be  directed  to  bear  down 
while  the  tractions  are  made.  As  the  placenta  clears  the  orifice,  and  gets 
into  the  excavation,  the  operator  changes  the  line  of  action,  and  gradually 
carries  the  cord  forward,  so  as  to  make  it  always  correspond  with  the  axis 
of  the  pelvic  canal.  Under  the  joint  influence  of  the  tractions  and  the 
patient's  bearing-down  efforts,  the  placenta  soon  reaches  the  vulva,  where 
it  is  seized  by  the  thumb  and  fingers  and  twisted  round  several  times,  so 
as  to  complete  the  detachment  of  the  membranes  and  form  them  into  a 
solid  cord,  for  the  double  purpose  of  preventing  their  laceration  and  of 
securing  their  entire  removal.1 

It  is  impossible  to  state  precisely  the  amount  of  force  which  may  be  used 
in  these  tractions  upon  the  cord,  and  it  must  be  left  to  the  intelligence  of 
the  practitioner  to  discover  what  is  proper  to  be  done.  When,  however, 
the  tractions  have  no  effect,  and  the  placenta  seems  to  rise  up  and  draw  the 
cord  after  it,  as  soon  as  they  have  ceased,  all  efforts  should  be  suspended  for 
the  time  being. 

"  When  the  placenta  is  partially  engaged  in  the  orifice  by  a  portion  of  its 
periphery,  this  plan,"  says  M.  Guillemot,  "  ought  to  be  somewhat  modified  ; 
for  in  this  presentation,  the  root  of  the  umbilical  cord,  instead  of  corre- 
sponding to  the  cervix,  is  higher  up  in  the  uterine  cavity ;  and  hence,  if  the 
operator  resorts  to  traction,  the  centre  of  the  placenta  will  have  a  tendency 

1  There  certainly  would  be  no  very  great  danger  in  leaving  a  portion  of  the  mem 
branes  in  the  uterine  cavity;  although,  in  addition  to  the  accidents  that  may  aviso 
from  the  presence  of  a  foreign  body  there,  the  following  phenomenon  might  possibly 
occur.  The  membranes  may  inclose  some  coagula,  and  thus  form  a  mass  whose  expul- 
sion is  often  difficult.  In  the  course  of  a  few  days,  the  uterus,  being  irritated  by  the 
presence  of  this  inconvenient,  lodger,  begins  to  contract,  and  the  woman  experiences 
some  colicky  pains,  varying  in  intensity  with  the  strength  of  the  contractions;  a  little 
blood  escapes  from  the  vulva,  and,  after  the  pains  have  lasted  for  a  longer  or  shorter 
period,  the  patient  is  finally  delivered  of  the  foreign  body,  or,  according  to  her  expres- 
sion, of  a  I  iryc  piece  of  flesh,  the  appearance  of  which  causes  great  alarm. 

Placental  Expression.  Crede's  Method.  Of  late  years,  delivery  of  the  placenta  by  com- 
pression of  the  uterus  has  been  practised  by  many  under  the  name  of  Crede's  method. 
The  plan  described  by  this  author  is  to  seize  the  uterus  with  the  hand,  the  lingers 
grasping  the  posterior  and  the  thumb  the  anterior  BUrface  of  the  fundus.  Owing  to 
contraction,  firm  compression  is  made,  thus  forcing  the  placenta  and  membranes  out 
of  the  womb.     (See  page  1073.) 

Playfair  recommends  thai  the  fundus  should  be  grasped  in  the  hollow  of  the  lefl 
hand,  the  ulnar  edge  being  well  pressed  down  behind,  and  when  the  uterus  is  felt  to  hardi  n 
Strong  and  firm  pressure  Should  be  made  downwards  and  backwards  in  the  axis  of 
the  brim.  The  uterine  surface  of  the  placenta,  by  this  method,  is  generally  the  lirsi 
expelled,  the  membranes  remaining  within  the  vagina. 

The  precaution  is  given  to  receive  the  placental  mass  in  the  palm  of  the  right  hand. 
to  avoid  any  strain  upon  the  membranes  which  mighl  otherwise  happen,  and  thus  leav< 
a  portion  within  the  uterus. 

One  objection  to  the  above  method  is  the  chance  of  part  of  the  membrane-  being 
torn  off  and  left  in  utero. 
25 


336  LABOlt. 

to  enter  the  orifice,  and  tluis  add  its  bulk  to  the  disk  already  engaged  there. 
Such  a  disposition  sometimes  constitutes  an  obstacle  to  the  further  delivery 
of  this  mass;  but  it  is  surmounted  by  making  some  moderate  tractions,  not 
nil  the  cord  itself,  but  rather  upon  the  part  previously  engaged,  by  applying 
two  fingers  on  its  surfaces."  We  have  had  numerous  opportunities  of  test- 
ing the  practical  utility  of  M.  Guillemot's  advice. 

'•  This  seems,"  says  Merriman,  "all  that  it  is  right,  to  do,  for  a  full  hour 
after  the  child  is  born ;  but  that  time  being  elapsed,  and  there  being  no 
reason  to  expect  that  uterine  contractions  will  spontaneously  arise,  the 
accoucheur  is  to  consider  whether  it  is  prudent  to  wait  longer,  before  he 
proceeds  to  extract  the  placenta,  by  introducing  his  hand  into  the  uterus. 

"If  no  bad  symptoms  are  present,  there  can  be  no  danger  in  allowing 
more  time  to  elapse  before  we  proceed  to  this  operation  ;  especially,  if  there 
be  reason  to  think  that  the  retention  arises  principally  from  the  exhausted 
state  of  the  patient;  because  it  is  possible  that  a  little  more  delay  will 
recruit  her  strength,  and  that  afterwards  sufficient  power  may  be  imparted 
to  the  uterus  to  expel  the  placenta. 

"  Yet,  generally  speaking,  we  can  have  but  little  expectation  that  the 
placenta  will  be  expelled  by  the  natural  powers,  after  it  has  been  retained 
much  more  than  an  hour ;  we  may,  therefore,  consider  ourselves  justified  in 
interfering  to  extract  it,  at  the  end  of  an  hour  or  two  after  the  child  is  born, 

"It  appears,  then,  to  be  a  question  of  prudence  or  discretion,  which  every 
accoucheur  must  judge  of  in  the  individual  case  he  is  attending,  whether  to 
proceed  to  delivery  at  the  end  of  the  hour,  or  to  wait  another  hour  or  two 
before  he  undertakes  this  operation.  But,  of  course,  this  only  applies  to 
cases  where  there  is  no  apparent  danger."     (Synopsis,  page  153.) 

"  The  time  for  interference  of  the  accoucheur  for  the  delivery  of  the 
placenta,  should  always  be  regulated  by  the  condition  of  the  uterus  itself," 
says  Dewees,  "  and  that  condition  is  whenever  it  is  firmly  contracted.  Time, 
simply  considered,  can  never  form  a  safe  rule  for  the  delivery  of  the  placenta  ; 
the  degree  of  contraction  of  the  uterus  alone  can  point  out  the  proper  moment 
to  operate,  or  teach  us  when  it  would  be  improper  to  attempt  it.  This  rule, 
I  believe,  will  never  deceive,  or  at  least  I  have  uniformly  acted  upon  this 
principle;  and,  so  far,  I  think  I  am  safe  in  saying,  I  have  not  had  cause  to 
believe  it  wrong."     (System  of  Midwifery,  page  447.) 

As  soon  as  the  placenta  is  delivered,  we  must  ascertain  whether  any  por- 
tion of  it,  or  of  the  membranes,  has  been  left  behind  in  the  womb ;  but  this 
is  easily  done  by  carefully  examining  the  secundines.  Should  it  happen  that 
the  membranes  or  after-birth  are  not  extracted  entire,  it  would  be  proper  to 
pass  the  hand  into  the  uterus,  for  the  purpose  of  removing  the  remnants. 

If  a  large  quantity  of  the  coagula  that  usually  accompany  the  placenta 
remains  in  the  womb,  they  may  subsequently  become  a  source  of  the  after- 
pains  yet  to  be  described.  Consequently,  if  there  is  reason  to  suspect  the 
presence  of  large  clots  in  the  womb,  the  latter  ought  to  be  stimulated  to 
contraction  by  repeated  frictions  over  the  hypogastrium.  Some  authors 
have  even  recommended  the  introduction  of  the  hand  into  the  uterine 
cavity,  so  as  to  rid  it  completely  of  all  foreign  bodies;  the  advice  is  good, 
but  to  be  followed  cautiously,  because,  on  the  one  part,  the  uterus  would 


DELIVERY   QF  THE   AFTER-BIRTH.  387 

be  unnecessarily  irritated,  and  on  the  other,  it  would  not  prevent  the  subse- 
quent formation  of  fresh  coagula. 

We  stated  above,  that  usually  in  the  course  of  fifteen,  twenty,  or  twenty- 
five  minutes  after  the  birth  of  the  child,  the  uterus,  by  contracting,  notifies 
the  accoucheur,  as  it  were,  of  the  proper  moment  for  his  intervention.  It 
should  always  be  remembered,  however,  that  moderate  tractions  are  all- 
sufficient  for  the  delivery  of  the  after-birth ;  and,  if  much  resistance  is  met 
with,  it  would  be  far  better  to  wait,  and  not  make  any  new  attempts,  until 
the  contractions  shall  have  partly  or  completely  overcome  the  obstacle. 

Where  there  is  the  least  reason  to  suspect  the  existence  of  a  second  child, 
after  the  birth  of  the  first,  the  physician  ought  to  satisfy  himself  on  that 
point,  both  by  an  external  and  an  internal  exploration,  before  attempting 
to  remove  the  placenta ;  and  should  a  twin  pregnancy  be  recognized  by  the 
great  size  of  the  womb,  and  more  particularly  by  the  vaginal  examination, 
a  ligature  is  to  be  applied  immediately  on  the  placental  extremity  of  the 
cord  belonging  to  the  first  infant ;  and  the  secundines  are  only  to  be 
extracted  after  the  expulsion  of  both  children.  If,  however,  the  placenta 
were  detached,  and  presented  at  the  orifice,  he  should  attempt  to  extract 
it,  more  especially  when  it  seems  to  obstruct  the  passage  of  the  second 
foetus.  Nevertheless,  such  tractions  ought  to  be  exceedingly  reserved ; 
because,  in  compound  pregnancies,  there  are  frequent  adhesions  between 
the  two  placentas ;  and,  if  this  were  the  case,  it  is  evident  that  any  forcible 
traction  might  detach  the  after-birth  of  the  second  child  long  before  its 
expulsion ;  and  this  premature  separation  would  render  the  mother  liable  to 
severe  hemorrhage,  and  the  child  to  fatal  asphyxia. 

After  the  birth  of  both  children,  so  far  from  pulling  on  the  two  cords 
simultaneously,  and  moderately  twisting  them  into  one,  it  is  more  prudent 
to  bring  down  the  placentas,  one  after  the  other,  giving  the  priority  to  the 
one  which  offers  the  least  resistance.  The  mass  of  these  conjoined  bodies  is 
made  to  engage  in  this  way  by  one  extremity ;  and  it  is  thus  enabled  to 
clear  the  uterine  orifice  more  readily. 

In  most  cases  of  compound  pregnancy  the  womb  is  excessively  distended, 
and  this  distention,  aa  we  are  all  aware,  is  one  of  the  circumstances  that  is 
most  likely  to  enfeeble  the  contractility  of  its  tissue ;  therefore  the  removal 
of  the  after-birth,  after  the  labor  is  over,  should  not  be  accelerated  too 
much,  and  the  womb  must  be  allowed  a  longer  time  than  usual  for  its 
retraction  ;  while  moderate  frictions  are  to  be  made  over  the  fundus  of  the 
organ  for  the  purpose  of  stimulating  its  action. 

As  regards  the  removal  of  the  secundines  after  a  miscarriage,  we  have 
nothing  t)  add  further  than  what  will  be  stated  in  the  article  on  Abortion. 


388  LABOR. 


CHAPTER   VII. 

OF   THE    NECESSARY    ATTENTIONS   TO    THE    WOMAN    AND    CHILD 
DURING    LABOR. 

ARTICLE   I. 

OF   THE   ATTENTIONS   TO    THE   WOMAN    DURING    LABOR. 

When  the  accoucheur  is  summoned  to  a  woman  in  labor,  he  shouH 
always  provide  himself  with  lancets,  a  female  catheter,  and  the  forceps; 
and,  if  in  the  country,  he  should  have  besides  some  ergot,  either  the  wine 
or  the  fluid  extract,  arid  one  or  two  drachms  of  Sydenham's  laudanum. 
His  arrival  ought  always  to  be  announced  before  entering  the  patient's 
chamber,  for  the  emotion  caused  by  a  sudden  entrance  often  proves  sufficient 
to  suspend  the  pains  for  a  considerable  time.  Then,  after  having  made  the 
usual  inquiries  as  to  the  time  at  which  the  pains  began,  their  frequency, 
their  duration  and  intensity,  he  might,  if  he  supposes  from  this  account  the 
labor  to  be  somewhat  advanced,  proceed  at  once  to  the  vaginal  exploration  ; 
in  the  contrary  case,  he  may  wait  a  few  minutes,  as  well  to  satisfy  himself 
of  the  value  of  the  communications  made  by  the  attendants,  as  to  give  the 
woman  time  to  prepare  for  the  examination.  When  he  finally  judges  this 
is  necessary,  he  is  to  proceed  with  all  possible  decency,  and  always  during 
the  interval  between  the  pains.  The  object  of  this  is  to  endeavor  to  ascer- 
tain: 1,  whether  the  woman  is  pregnant;  2,  if  she  is. in  labor;  3,  if  she  is 
at  full  term  ;  4,  whether  the  membranes  are  ruptured  ;  5,  whether  the  labor 
is  far  advanced;  6,  what  is  the  condition  of  the  cervix,  vagina,  and  perineum, 
and  their  degree  of  suppleness  or  resistance;  7,  what  is  the  conformation  of 
the  pelvis;  8,  lastly,  what  part  of  the  child  presents. 

At  first  sight,  it  may  seem  a  ridiculous  precaution  to  attempt  to  verify 
the  existence  of  the  pregnancy  in  a  woman  who  declares  she  is  actually 
suffering  from  the  pains  of  childbirth  ;  but,  to  say  the  least,  this  is  not 
altogether  useless,  since  it  has  unfortunately  happened  that  some  over-con- 
tident  accoucheurs  have  been  imposed  upon  by  women  who  were  themselves 
deceived  as  to  the  nature  of  the  pains  they  felt;  and  we  might  quote  many 
instances  where,  after  having  waited  for  the  delivery  to  take  place  for 
several  days,  they  have  ultimately  been  constrained  to  acknowledge  their 
mistake.  Besides,  this  error  is  easily  avoided  by  bearing  in  mind  the 
diagnostic  signs  pointed  out  in  the  article  on  Pregnancy. 

After  observing  the  progress  of  the  pains  for  some  instants,  he  should 
next  endeavor  to  ascertain  their  cause  and  nature,  in  order  to  favor  those 
which  have  a  bearing  on  the  labor,  and  to  combat  any  that  are  foreign 
thereto.  Women  are  not  unfrequently  tormented  by  pains  during  the  latter 
stages  of  gestation,  which  are  dependent  on  some  sympathetic  disorder  of 
the  intestines,  or  abdominal  organs,  and  which  even  a  physician  might  mis- 
take for  the  commencement  of  labor ;  these  have  been  denominated  the 
false  pains,  by  way  of  distinguishing  them  from  those  produced  by  the  con- 
traction of  the  womb.     The  true  and  the  false  pains  may  be  recognized  by 


ATTENTIONS   TO    THE    WOMAN    AND    CHILD.  389 

trie  following  characters:  the  latter  are  ordinarily  seated  m  the  region 
occupied  by  the  diseased  organ,  while  those  occasioned  by  the  commence- 
ment of  the  travail  usually  begin  about  the  umbilicus  and  loius,  and  die 
away  at  the  perineum,  the  anus,  or  the  sexual  parts;  the  false  are  almost 
continuous,  and  their  intensity  is  nearly  uniform ;  the  others,  on  the  con- 
trary, are  intermittent.  If  the  irregularity  in  the  return  and  progression 
of  the  pains  be  such  as  to  leave  any  doubt  as  to  their  character,  he  should 
interrogate  the  neighboring  organs,  and  by  a  little  attention  he  will  suc- 
ceed in  determining  their  seat  and  nature.  There  are,  however,  certain 
pains  which  have  their  seat  in  the  uterus  itself,  affect  a  certain  degree  of 
regularity,  and  simulate  a  true  labor,  which  are  dependent  on  a  plethoric 
condition  of  the  organ,  that  may  be  calmed  by  rest,  a  restricted  diet,  and 
blood-letting.  Further,  the  epoch  at  which  they  occur,  and  the  absence  of 
the  other  phenomena  of  labor,  will  serve  to  lessen  the  difficulties  in  deter- 
mining the  diagnosis ;  nevertheless,  it  is  the  touch  alone  that  can  dispel  all 
doubts ;  for  the  hardness  that  comes  on  in  the  uterine  globe,  the  rigidity  in 
the  circumference  of  the  os  uteri,  the  tension  and  protrusion  of  the  mem- 
branes during  the  pain  itself,  together  with  the  retreat  and  relaxation  of  all 
these  parts  in  proportion  as  it  diminishes,  characterize  the  pains  of  child- 
birth in  an  infallible  manner. 

"  By  examining,"  says  Wigand,  "  the  course  of  the  true  contractions,  it 
will  be  found  that  they  commence  at  the  cervix,  and  pass  to  the  fibres  of  the 
fundus,  which  are  then  thrown  into  action ;  and  hence  all  contractions  that 
begin  in  this  latter  part  of  the  womb  are  anomalous,  and  result  either  from 
some  disorder  having  occurred  in  the  uterine  forces,  or  else  they  are  pro- 
duced by  an  inflammation,  or  a  disturbance  in  the  functions  of  a  neighbor- 
ing organ."  When  the  true  pain  is  manifested,  the  head,  which  reposed 
during  the  interval  on  the  cervix,  sometimes  mounts  up  even  beyond  the 
reach  of  the  finger,  but  the  membranes  engage  more  or  less  in  the  orifice. 
In  the  course  of  a  few  seconds,  the  contraction  extends  all  over  the  uterus, 
and  more  particularly  to  the  fibres  of  the  fundus;  and  the  head,  which  was 
at  first  elevated,  is  forcibly  pressed  down  on  the  neck,  thus  assuming  the 
office  of  a  wedge  for  hastening  its  dilatation;  and,  as  a  general  rule,  it  is 
only  when  the  fundus  contracts  in  this  manner,  that  the  woman  complains 
of  pain.  We  may,  therefore,  consider  the  true  pain  as  constituted  of  a 
series  of  phenomena,  which  succeed  each  other  in  the  following  order:  first, 
the  periphery  of  the  cervix  becomes  tense ;  then,  the  presenting  part  ascends, 
and  the  membranes  bulge  out;  next,  the  remainder  of  the  uterus,  the  fundus 
especially,  becomes  hard,  during  which  the  patient  complains  of  a  sharp 
pain  ;  and,  lastly,  the  part  that  presented  endeavors  anew  to  engage.  It  is 
unnecessary  to  add,  that  the  rapidity  with  which  these  phenomena  succeed 
each  other  necessarily  varies  according  to  the  individual,  to  the  irregulari- 
ties to  which  the  process  is  subject,  and  according  to  the  stage  of  the  labor. 
Other  things  being  equal,  the  contractions  will  effeel  the  dilatation  so  much 
the  soouer,  in  proportion  as  the  cervix  shall  correspond  more  directly  to  the 
fundus  of  the  organ,  and  the  uterine  axis  shall  he  the  more  parallel  to  that 
of  the  pelvis. 

After  having  learned  the  true  character  of  the  pains,  the  accoucheur  ncx' 


390  LABOR. 

endeavors  to  ascertain  whether  the  woman  is  really  at  term,  so  as  not  to 
encourage  a  premature  labor,  which  might  often  be  prevented  if  he  knew 
its  cause.  He  ought,  therefore,  to  recall  the  various  signs,  by  means  oi 
which  we  have  attempted  to  characterize  the  different  periods  of  pregnancy. 
Thus,  should  he  find  that  the  cervix  is  not  yet  entirely  effaced,  that  it  still 
retains  a  certain  degree  of  length,  that  it  is  hard  and  resistant  even  during 
the  interval  of  the  contractions ;  that  the  hitter  are  much  less  regular  in 
their  course,  duration,  and  return,  than  in  parturition  at  full  term  ;  and 
the  belly  not  yet  sunk  down;  he  may  justly  conclude  that  the  patient  has 
not  yet  reached  the  end  of  the  ninth  month  ;  also,  that  such  a  premature 
labor  is  owing  either  to  some  acute  moral  emotion,  or  some  antecedent 
external  violence.  In  all  cases,  he  ought  to  attempt  the  arrest  of  this 
premature  or  false  labor,  by  rest,  both  of  body  and  mind,  by  venesection, 
if  the  woman's  general  condition  will  admit  of  it,  and,  more  especially,  by 
the  administration  of  laudanum  in  full  doses,  taking  care  to  empty  the 
bladder  when  necessary,  and  to  keep  the  bowels  free  by  mild  laxatives. 

The  use  of  means  to  stop  the  premature  labor  ought  not  to  be  given  up, 
even  though  the  cervix  be  entirely  effaced,  the  orifice  somewhat  dilated,  and 
a  certain  amount  of  water  discharged  ;  inasmuch  as  the  escaped  fluid  might 
proceed  from  a  hydrorrhoea  and  not  from  within  the  amnios,  whilst  prema- 
ture pains  can  sometimes  be  calmed  and  the  pregnancy  enabled  to  proceed 
to  full  term. 

Very  conclusive  observations  on  this  point  were  published  in  1857  by  Dr. 
Charrier:  he  cited  cases  in  which  the  dilatation  equalled  a  quarter  of  a 
dollar  in  size,  and  in  which  the  pains  were  suspended  notwithstanding  the 
membranes  were  engaged  in  and  projecting  from  the  orifice.  The  cervix 
afterwards  closed  in  such  a  way  as  to  reproduce  its  external  orifice,  and  to 
present  the  conical  shape  which  it  has  in  the  eighth  month  of  gestation.  This 
phenomenon,  styled  by  M.  Charrier,  retrocession  of  labor,  though  doubtless 
rare,  need  only  be  possible  in  order  to  encourage  the  practitioner  to  suspend 
the  labor  whenever  he  is  sure  the  membranes  are  intact,  the  child  alive,  and 
the  woman  not  at  term. 

However,  there  is  one  phenomenon,  sometimes  manifested  in  the  latter 
weeks  of  gestation,  which  may  place  the  most  skilfui  practitioner  at  fault. 
1  allude  to  what  has  been  designated  as  the  false  labor,  in  which  certain 
women,  after  having  nearly  reached  their  full  term,  experience  the  true 
contractions ;  the  pains  are  regular,  the  membranes  bulge  out,  and  the  os 
uteri  dilates  ;  at  times,  these  pains  last  from  four  to  six  hours,  but  then  they 
disappear  all  at  once,  and  everything  goes  on  as  usual.  In  others,  the  false 
labor  is  kept  up  at  first  during  several  hours,  and  then  it  passes  off,  return- 
ing in  this  manner  every  day,  particularly  towards  the  evening,  and  lasting 
one  or  two  weeks.     (See  Uterine  Rheumatism.) 

When  the  accoucheur  is  very  sure  that  the  woman  is  really  in  labor,  his 
attention  must  be  directed  to  the  frequency  and  the  intensity  of  the  pains, 
and  to  the  dilatation,  the  hardness,  and  thinness  of  the  cervix,  in  order  to 
judge  of  its  probable  duration.  During  the  same  exploration,  he  should 
ascertain  the  conformation  of  the  pelvis,  particularly  if  the  woman  happens 
to  be  in  her  first  confinement,  and  it'  any  apparent  deformities  exist;  he 


ATTENTIONS    TO   THE    WOMAN    AND    CHILD.  891 

should  also  learn  the  situation  of  the  orifice,  the  obliquity  of  the  body  and 
neck  4)f  the  womb,  and  the  child's  presenting  part.  (See  Mechanism  of 
Labor.)  If  this  latter  is  so  high  up  as  to  render  the  diagnosis  of  the  pre- 
sentation difficult,  its  examination  should  be  deferred  until  a  more  advanced 
period  of  the  labor;  but  the  bag  of  waters  is  never  to  be  ruptured,  in  any 
case,  for  the  mere  purpose  of  rendering  this  examination  more  easy,  before 
the  entire  dilatation  of  the  neck  ;  for  such  an  untimely  rupture  of  the  mem- 
branes would  be  attended  by  very  great  inconveniences,  if  the  position  were 
at  all  defective ;  for,  all  the  waters  escaping,  the  foetus  might  suffer  from 
the  pressure  exercised  directly  upon  it  by  the  uterine  walls;  the  umbilical 
cord  would  be  compressed  ;  and  the  womb,  irritated  by  the  prolonged  con- 
tact of  the  foetal  inequalities,  might  be  affected  with  spasmodic  contrac- 
tions;  and,  finally,  the  intervention  of  art  becoming  necessary,  long  alter 
the  evacuation  of  the  waters,  the  necessary  manipulations  would  be  attended 
with  much  greater  difficulties. 

But  it  is  not  always  so  easy  a  matter  as  one  might  imagine  to  ascertain 
whether  the  membranes  are  ruptured  or  are  still  intact;  for  instance,  where 
the  vaginal  examination  is  resorted  to  between  the  pains,  in  a  vertex  pre- 
sentation, they  are  often  applied  so  directly  to  the  scalp  that  it  is  impossible 
to  distinguish  them.  A  pain  should  then  be  waited  for,  because,  as  soon  as 
the  uterus  contracts,  it  drives  the  waters  towards  the  lower  parts,  and  the 
finger  is  observed  to  be  raised  up  by  a  small  quantity  of  this  fluid  that  in- 
sinuates itself  between  the  head  and  the  amniotic  sac,  the  integrity  of  which 
latter  is  thereby  easily  verified  ;  but  where  the  head  is  more  deeply  engaged, 
this  afflux  of  liquid  is  very  inconsiderable,  and  the  tension  of  the  mem- 
branes can  scarcely  be  distinguished.  Consequently,  attention  should  be 
given  to  the  state  of  the  tumor  both  during  and  after  the  contraction. 
Where  the  waters  have  escaped,  and  the  finger  comes  directly  upon  the 
child's  cranium,  it  will  detect  the  hairy  scalp  puckering  up  while  the  pain 
lasts,  and  becoming  smooth  and  even  as  soon  as  it  shall  have  ceased  ;  though 
the  contrary  will  take  place  when  the  membranes  are  intact,  for  they  are 
never  more  smooth  or  more  tense  than  during  the  contraction  itself. 

It  is  difficult  at  times  to  reach  the  cervix  uteri  in  the  commencement  of 
the  iabor,  because  it  is  then  carried  so  far  backwards  that  the  plane  of  its 
orifice  actually  looks  towards  the  anterior  face  of  the  sacrum.  I  have  often 
seen  young  practitioners  who  were  unable  to  get  at  it  at  all,  and  others, 
who,  not  finding  the  os  uteri,  and  distinctly  feeling  the  child's  head  through 
the  anterior  inferior  part  of  the  womb,  which  is  then  rendered  very  thin  by 
the  distention  it  has  undergone,  have  imagined  that  the  dilatation  was  al- 
ready completed,  whereas  it  had  hardly  commenced;  the  disastrous  conse- 
quences to  which  such  an  error  might  Lead,  can  be  readily  imagined.  In 
fact,  it  is  very  often  necessary  to  pass  the  finger  around  the  convex  tumor 
which  fills  the  excavation,  in  oi'der  to  get  the  index  far  enough  upwards 
and  backwards,  where  the  uterine  orifice  is  to  be  found. 

All  these  questions  being  determined,  the  accoucheur's  attention  should 
be  directed  early  in  the  progress  of  the  confinement  to  having  the  woman 
moved  into  the  most  suitable  place.  The  chamber  intended  for  her  lying-in 
should  be  spacious,  airy,  well  lighted,  and  retired  ;  the  air  she  respires  ought 


392  LABOR. 

to  be  pure  and  of  a  moderate  temperature,  and  all  strong  odors,  whethei 
good  or  bad,  should  be  excluded.  A  temperature  too  elevated  will  predis 
pose  her  to  nervous  agitation,  and  to  hemorrhagic  accidents;  and,  on  the 
other  hand,  the  impression  ol*  culd  is  a  very  frequent  cause  of  acute  inflam- 
mation, or  of  chronic  engorgements,  such  as  those  that  often  come  on  aftei 
delivery,  which  have  for  so  long  a  time  been  attributed  to  lacteal  metas- 
tasis.  But  few  persons  are  to  be  admitted  in  the  chamber,  and  all  those, 
especially,  whose  presence  is  at  all  unpleasant  to  her,  ought  to  be  rigidly 
excluded.  This  latter  point  demands  the  greatest  care  on  the  part  of  the 
physician,  for  it  is  he  alone  who  has  authority  thus  to  dismiss  such  as  ho 
may  think  useless  or  injurious,  and  he  must  judge,  from  the  reception  given 
to  each,  of  the  pleasure  or  otherwise  the  patient  experiences  from  their  pre- 
sence. Some  women  are  almost  ashamed  of  being  delivered  in  the  presence 
of  the  husband ;  with  others,  on  the  contrary,  it  is  one  of  the  greatest  con- 
solations to  have  him  near  them,  and  the  accoucheur  must  endeavor  to  dis- 
cover all  the  little  shades  of  delicacy  and  feeling,  to  sound,  by  discreet  and 
artful  questions,  a  wish  that  the  woman  herself  at  times  fears  to  express, 
and,  alter  having  once  learned  it,  he  should  religiously  comply  with  it.  As 
a  general  rule,  the  mother  and  sister,  or  two  intimate  friends  of  the  patient, 
besides  the  nurse,  are  the  only  ones  that  are  to  be  allowed  to  stay  in  the 
room.  With  regard  to  dress,  her  garments  should  be  full,  sufficiently  so, 
as  neither  to  incommode  her  movements  nor  her  respiration. 

If  some  time  has  elapsed  since  she  has  had  a  passage  from  the  bowels,  a 
simple  injection  must  be  given  ;  and  where  this  does  not  prove  sufficient  to 
procure  a  stool,  a  second  is  to  be  immediately  administered  with  the  addi- 
tion of  one  or  two  ounces  of  the  miel  mercuriale.1  The  evacuation  of  the 
matters  contained  in  the  rectum  is  the  more  necessary,  as  its  distention 
might  subsequently  retard  the  escape  of  the  head,  and  likewise  prevent  that 
of  the  intestinal  gases,  whose  accumulation  might  bring  on  colic  and  grip- 
ings;  besides,  this  precaution  has  the  advantage  of  sparing  the  woman  the 
shame  and  disgust  which  an  involuntary  expulsion  of  the  faeces  during  the 
last  moments  of  labor  would  necessarily  cause,  as  also  of  preventing  the 
accoucheur's  hand  from  being  soiled,  while  it  supports  the  perineum. 

The  accumulation  of  urine  in  the  bladder  ought  likewise  to  be  prevented, 
by  persuading  the  patient  to  urinate  in  the  very  commencement  of  her  par- 
turition ;  for,  where  she  has  not  observed  this  precaution,  or  the  physician 
arrives  too  late  to  insist  upon  it,  the  emission  of  water  becomes  more  and 
more  difficult,  and  sometimes  quite  impossible,  owing  to  the  compression 
which  the  head,  engaged  at  the  superior  strait,  makes  on  the  neck  of  the 
bladder.  In  such  cases,  he  should  endeavor  to  push  the  head  up  somewhat 
bv  two  fingers,  so  that  she  can  urinate ;  and  if  this  does  not  succeed,  the 
catheter  must  be  resorted  to.  We  have  elsewhere  stated  that  it  was  advis- 
able, under  such  circumstances,  to  use  a  male  catheter,  the  curvature  of 
which  is  greater;  though,  even  by  taking  this  precaution,  a  considerable 
resistance  is  occasionally  experienced  to  its  introduction.     This  condition 

i  This  preparation  is  only  used  as  an  injection  ;  it  is  prepared  by  taking  equal  parts 
of  clarified  honey  and  the  juice  of  the  mercurialia  annua,  a  plant  belonging  to  the  tribf 
of  the  Euphorbiaceae,  an  1  reducing    hem  to  the  consistency  of  a  syrup.  —  Translato" 


ATTENTION'S     TO    THE    WOMAN    AND    CHILD.  393 

requires  the  most  careful  manipulation;  the  woman  must  lie  flat  on  her 
back,  and  then,  with  one  hand  the  womb  is  pressed  backwards  from  the 
strait,  or  what  is  preferable,  while  the  head,  which  by  its  presence  in  the 
lesser  pelvis  compresses  the  urethra,  is  raised  by  two  fingers  in  the  vagina, 
the  other  introduces  the  instrument  into  the  urethra. 

The  accumulation  of  urine  is  attended  with  such  grave  consequences  as 
to  warrant  a  persevering  effort  to  introduce  the  catheter.  The  least  of  all 
the  accidents  which  may  result  therefrom,  is  a  relaxation,  or  even  the  total 
cessation  of  the  pains ;  for  the  distressing  sensation  caused  by  a  distention 
of  this  organ,  which  is  increased  when  the  abdominal  muscles  contract, 
induces  the  woman  to  suspend  the  contractions  as  much  as  possible;  besides 
which,  the  pain  itself  is  sometimes  so  acute  as  to  paralyze,  as  it  were,  the 
action  of  these  muscles  ;  and  again,  as  they  are  separated  from  the  uterine 
walls  by  the  mass  of  urine  shut  up  in  the  bladder,  their  action  is  trans- 
mitted to  the  womb  in  but  a  very  feeble  manner.  The  paralysis  of  the 
bladder,  so  often  met  with  after  labor,  is  a  common  consequence  of  pro- 
longed retention  of  the  urine;  and  finally,  the  Avails  of  this  reservoir  are 
occasionally  ruptured  just  at  the  moment  when  the  woman  gives  way  to  the 
most  violent  bearing-down.  Doubtless  this  last  accident  is  rare,  but  still  it 
is  not  without  example,  since  Ramsbotham,  Sen.,  has  observed  two  cases  of 
the  kind.  (  Obs.  Pract.,  cases  89,  90.) l  The  tumor  thus  formed  by  the  over- 
distended  organ  may  easily  be  recognized,  more  particularly  after  the  rup- 
ture of  the  membranes,  by  the  soft,  fluctuating  tumefaction  detected  imme 
diately  above  the  pubis,  extending  at  times  nearly  as  high  as  the  umbilicus, 
at  the  side  of,  and  behind  which,  the  hard  resistant  mass  constituted  by  the 
uterus  can  be  distinguished,  whose  consistence  varies  according  to  whether 
the  examination  is  made  during  or  after  pain. 

He  should  also  attend  early  to  having  everything  prepared  that  may  be 
wanted  somewhat  later ;  thus,  the  thread  intended  for  the  ligature  of  the 
cord  is  to  be  laid  out,  and  the  band  and  linen  for  covering  the  child's  navel 
are  to  be  cut;  for  the  mother,  he  ought  to  procure  some  cold  iced  water, 
vinegars,  and  smelling-salts,  agents  that  will  probably  be  unnecessary,  but 
which,  notwithstanding,  he  ought  always  to  have  at  hand ;  and,  lastly,  he 
must  direct  the  preparation  of  the  bed  upon  which  the  woman  is  to  be 
delivered.  This  bed  (called  the  lying-in  bed,  the  bed  of  misery,  or  the  little 
bed)  is  arranged  in  the  following  manner:  one  with  a  sacking-bottom  is 
procured,  of  a  moderate  height,  and  about  two  feet  to  two  and  a  half  in 
width,  and  one  end  of  it  is  placed  against  the  wall,  being  careful  to  keep  it 
clear  on  both  sides,  so  that  one  can  pass  freely  all  around  it.  A  first  mat- 
tress is  placed  on  the  bottom,  and  upon  this  a  second,  which  covers  its  upper 
part,  and  is  folded  double  towards  its  superior  third,  in  such  a  way  as  to 
leave  the  first  one  uncovered  about  the  foot.     An  oil-cloth,  then  a  sheet, 

1  The  symptoms  of  this  accident  are  very  similar  to  those  of  a  rupture  of  the  womb, 
excepting  that  the  child  remains  in  situ.  There  is,  besides,  a  sudden  and  sharp  pain 
in  the  vesical  region,  and  the  patient  complains  of  the  sensation  caused  by  the  effusion 
of  the  liquid  into  the  abdominal  cavity,  syncope,  &c.  The  signs  peculiar  to  the  vesical 
rupture  are  the  collapse  and  disappearance  of  the  tumor  previously  formed  by  the 
bladder  (nhich  could  be  felt  above  the  pubis),  and  an  obscure  fluctuation  in  the  belly 


394  LABOR. 

some  pillow?,  and  a  coverlet,  complete  the  furniture  of  the  bed.  A  s  did 
bar  is  placed  transversely  across  the  foot  of  the  bed,  so  as  to  give  the 
woman's  feet  a  solid  point  of  resistance  in  the  last  moments  of  her  labor. 
In  France,  the  patient  is  so  placed  that  the  upper  part  of  her  back  rests  on 
the  inclined  plane  formed  by  the  second  mattress,  and  her  breech  at  the 
margin  of  the  same  mattress  ;  the  inferior  extremities  are  slightly  flexed, 
and  the  feet  press  against  the  transverse  bar  placed  at  the  foot  of  the  bed. 
In  England,  women  are  delivered  on  the  edge  of  their  beds ;  they  lie  on  the 
left  side,  having  their  legs  and  thighs  flexed,  and  their  knees  separated  by 
pillows.  In  Germany,  the  lying-in  chair  of  the  ancients  is  used  ;  the  patient 
is  placed  on  an  inclined  plane,  which  can  be  modified  at  will,  by  lowering 
or  raising  the  back,  by  means  of  a  rack  ;  the  woman  then  draws  on  the  arms 
of  the  chair,  and  presses  her  feet  against  the  rounds  with  which  it  is  sup- 
plied, and,  as  she  gives  way  to  the  throes  of  labor,  the  sexual  parts  are 
uncovered,  and  correspond  to  the  opening  made  in  the  edge  of  the  seat. 
But,  on  the  whole,  the  bed,  furnished  as  we  have  described,  appears  prefer- 
able, the  more  so,  because  it  is  always  at  hand ;  and,  as  suggested  bv  Desor- 
meaux,  it  is  particularly  suitable  where  the  woman  must  remain  recumbent 
during  the  whole  progress  of  labor,  as  is  necessary  whenever  she  is  affected 
with  hernia,  or  is  threatened  with  hemorrhage,  prolapsus,  or  a  displacement 
of  the  womb.  In  case  of  necessity,  its  place  might  be  supplied  by  a  table 
and  a  few  chairs  placed  against  the  wall.  It  would  be  much  better,  say 
Desormeaux  and  M.  P.  Dubois,  where  the  family  are  in  easy  circumstances, 
to  make  use  of  an  ordinary  bed,  taking  care,  however,  to  supply  it  with  a 
rather  hard  mattress,  and  a  hard  cushion  near  the  buttocks,  to  prevent  the 
pelvic  region  from  sinking  down  into  the  substance  of  the  mattress,  and  the 
borders  of  the  hole  thereby  produced,  from  forming  an  obstacle  to  the 
extension  of  the  coccyx,  or  the  escape  of  the  child's  head.  On  this  bed,  the 
woman  is  more  at  ease  ;  she  can  lie  on  her  side,  or  take  the  most  convenient 
attitudes,  and  even  sleep  during  the  intervals  of  the  pains  ;  and  then,  after 
the  delivery,  she  may  remain  there  some  tiim  before  being  transported 
to  another. 

Ought  the  accoucheur  to  remain  constantly  with  the  patient?  This  is  a 
(piestion  whose  solution  varies  according  to  the  character  of  the  female  her- 
self, and  the  greater  or  less  intimacy  existing  between  her  and  her  physician, 
lor  there  are  some  timid  women  who  desire  to  have  him  always  close  at 
hand,  and  others  again,  who  are  impatient  and  annoyed  by  his  continual 
presence.  But  in  all  cases,  he  should  bear  in  mind  that,  during  parturition, 
the  patient  very  often  wishes  to  urinate  or  to  empty  her  bowels,  and  lie 
ought,  therefore,  to  go  from  time  to  time  into  an  adjoining  chamber,  in  order 
to  give  her  the  desired  opportunity.  Again,  during  the  labor,  a  wife  is  fre- 
quently cheered  up  by  the  caresses  and  consolations  bestowed  by  her  husband; 
the  physician  will  understand  that  his  presence  at  such  times  must  act  as  a 
restraint,  and  lie  should  discreetly  withdraw,  or,  at  least,  not  observe  what 
is  going  on.  Further,  he  may  absent  himself  more  frequently  during  the 
period  of  the  dilatation;  for  instance,  after  having  made  the  examination, 
and  ascertained  that  the  child's  presentation  and  position  are  both  favor 
nble,  he  might,  if  the  cervix  was  just  beginning  to  dilate,  attend  to  his  othei 


ATTENTIONS     TO     THE     WOMAN     AND     CHILD.  395 

occupations,  and  return  again  in  the  course  of  a  couple  of  hours;  but  if  the 
diagnosis  of  the  position  had  been  impossible,  or  if  the  latter  had  proved  to 
he  an  unfavorable  one,  he  must  not  quit  her  under  any  pretext,  in  order  to 
be  always  ready  to  ward  off  any  accidents  which  might  subsequently  demand 
his  intervention.  When  the  stage  of  expulsion  commences,  the  accoucheur 
places  himself  at  the  right  of  the  bed,  on  a  chair  of  a  suitable  height.  The 
part  he  has  to  perform  consists,  in  a  natural  labor,  in  ascertaining  its  pro- 
gress, from  time  to  time,  by  the  touch,  in  directing  properly  the  bearing 
down  efforts  of  the  patient,  and  in  sustaining  the  perineum  with  his  hand 
while  the  child's  head  is  passing  through  the  vulva. 

During  the  first  stage,  the  woman  may  lie  down,  sit  down,  or  walk  about, 
at  her  pleasure ;  indeed,  this  frequent  change  of  position  renders  the  slow- 
ness and  fatigues  of  childbirth  more  supportable ;  but,  at  the  end  of  this 
stage,  when  the  dilatation  is  completed,  and  the  amniotic  sac  projects 
strongly,  and  is  on  the  point  of  yielding,  she  must  then  resume  her  bed ; 
and  this  precaution  is  particularly  indispensable  in  those  who  have  already 
borne  several  children  ;  because,  in  them,  the  expulsion  of  the  foetus  some- 
times follows  so  promptly  after  the  rupture  of  the  membranes,  that  the 
patient  has  not  always  the  time  to  regain  her  bed,  and  is  liable  to  be  deliv- 
ered standing.  But  when,  after  the  rupture,  the  progress  of  the  labor  is 
slow,  and  the  head  is  more  or  less  engaged  in  the  excavation,  or  has  already 
descended  as  low  as  the  perineum,  but  does  not  advance,  and  the  pains  seem 
to  become  more  and  more  feeble  and  distant,  it  is  advisable  to  recommend 
her  to  get  up  and  walk  about,  having  her  supported  by  assistants,  if  her  own 
strength  does  not  permit  her  to  walk  alone,  for  it  is  found  by  experience 
that  bodily  motion  seems  to  give  more  activity  to  the  uterine  contractions. 
In  the  contrary  case,  she  must  not  leave  the  bed  without  some  special  indica- 
tion. Where  the  patient  is  tormented  by  pains  in  the  loins,  we  may  relieve 
them  by  stretching  a  folded  napkin  under  the  small  of  the  back,  and  direct- 
ing two  persons,  placed  at  the  opposite  sides  of  the  bed,  to  pull  on  the  ex- 
tremities of  the  towel  during  the  pain.  Attempts  should  be  also  made  to 
assuage  the  cramps,  so  often  experienced  in  the  thighs  and  calves  of  the 
legs,  by  voluntary  contraction  of  the  antagonist  muscles  of  the  suffering 
ones,  which  will  be  far  more  effectual  than  frictions  over  the  suffering  parts. 

Some  nervous  women  are  troubled  with  tremblings  and  chills,  in  the  very 
commencement  of  their  labor,  which  are  at  times  sufficiently  marked  to 
cause  much  disquietude.  Dewees  observed  that  they  often  coincide  with  an 
unusual  rapidity  in  the  dilatation  of  the  cervix,  and  he  says:  "  A  lady,  who 
every  moment  expected  her  labor  to  commence,  was  awakened  suddenly  in 
the  night  by  a  violent  chill.  The  nurse  became  alarmed,  and  I  was  imme- 
diately sent  for.  When  I  arrived,  I  found  her  still  trembling  very  severely, 
but  she  had  not  experienced  any  symptoms  of  labor;  she  assured  me  that 
nothing  was  the  matter  with  her  except  what  I  was  witnessing,  namely,  an 
agitation  of  the  whole  body,  which  she  could  not,  by  any  effort,  control.  In 
about  five  minutes,  she  cried  out  she  believed  her  labor  was  coming  on  ;  and 
this  really  was  the  case,  and  so  rapidly  as  not  to  give  me  time  to  place  her 
in  a  proper  situation  for  delivery;  she  was  delivered  in  less  than  live 
mir.utes  from  the  time  she  first  called   my  attention  to  her.     These  shiver 


396  LABOR. 

ings  are  sometimes  renewed  during  or  immediately  after  the  labor,  oui.  hi 
no  ease  do  they  merit  a  serious  attention." 

Patients  are  often  frightened  at  the  time  the  bag  of  waters  is  torn,  and  it 
is  therefore  a  good  plan  to  advise  them  of  it  beforehand;  and  the  precau- 
tion should  also  be  taken  of  placing  a  sponge  or  some  old  linen  near  the 
genital  parts,  so  as  to  receive  the  liquids  as  they  escape.  Immediately  after 
the  discharge  of  the  waters,  it  is  advisable  for  the  practitioner  to  assure 
himself  anew  of  the  presentation  and  position,  lest  he  might  have  been 
deceived  in  the  first  examination. 

The  rupture  of  the  membranes  generally  takes  place  spontaneously,  but 
this  is  not  always  the  case,  and  the  accoucheur  must  sometimes  interfere. 
It  is  very  certain  that  when  the  uterine  orifice  is  entirely  dilated,  when  the 
membranes  are  forced  into  the  vagina  by  a  large  quantity  of  fluid,  and  the 
head  is  movable,  but  still  the  contractions  do  not  produce  a  spontaneous 
rupture  of  the  membranes, —  it  is  evident,  we  repeat,  that  they,  by  their 
resistance,  prolong  the  labor.  Although  this  obstacle  is  never  insurmount- 
able, by  the  efforts  of  nature  alone,  yet  the  delay  in  the  delivery  and  the 
dragging  on  the  membranes  may  be  attended  with  some  inconveniences, 
and  it  is  therefore  better  to  lacerate  them.  This  is  done  by  taking  advan- 
tage of  a  strong  contraction,  and,  while,  they  are  greatly  distended,  forcibly 
pressing  the  index  finger  against  the  centre  of  the  tumor. 

When  this  rough  pressure  is  not  sufficient,  we  scratch  the  membranes 
with  the  finger-nail ;  and  by  gradually  weakening  the  three  tunics,  succeed 
in  rupturing  them.  Sometimes,  however,  they  still  resist,  and  then  some 
instrument,  such  as  a  blunt  probe,  or,  still  better,  the  end  of  a  quill  cut 
down,  is  directed  up  to  them  along  the  finger.  M.  Dubois  made  for  the 
same  purpose  a  very  convenient  instrument,  consisting  merely  of  a  piece  of 
whalebone  sharpened  at  one  end.  Where  the  waters  breflat,  that  is,  when 
but  little  liquid  intervenes  between  the  membranes  and  the  head,  some  care 
is  requisite,  in  using  the  little  instrument,  to  direct  it  obliquely,  so  as  not  to 
wound  the  foetus  with  its  point.  Rupturing  the  membranes  is,  therefore, 
a  trilling  operation  ;  still,  excepting  in  some  rather  rare  cases  to  be  spoken  of 
hereafter,  it  ought  not  to  be  performed  until  after  the  orifice  is  thoroughly 
dilated.  Whatever  the  presenting  part  may  be,  there  is  always  an  ad- 
vantage in  retaining  a  large  amount  of  fluid  in  the  uterus. 

Some  peculiar  circumstances  may,  however,  demand  the  artificial  rupture 
before  the  dilatation  is  completely  effected. 

In  a  ease  reported  by  Baudelocque,  the  child  was  so  movable,  that  it  suc- 
cessively  presented  every  part  of  the  surface  of  its  body  at  the  os  uteri.  In 
a  woman  whose  belly  was  distended  by  a  great  quantity  of  water,  M.  Martin, 
of  Lyons,  had  recognized  the  feet  and  one  hand  through  the  membranes. 
'•I  then  felt  disposed,"  says  he,  "to  terminate  the  labor,  when,  at  the 
request  of  her  husband,  I  called  a  friend  in  consultation;  but  on  touching 
her  again,  before  his  arrival,  I  detected  the  head  where  I  had  previously 
found  the  feet  and  hand,  when  I  immediately  punctured  the  membranes, 
whereby  the  head  was  fixed  at  the  superior  strait  and  the  delivery  rendered 
natural."  I  Cmnj,!.*  Rendus,  p.  155.)  Should  a  case  of  this  nature  be  met 
with,  the  rule  we  have  just  given  might  be  laid  aside,  and  the  membrane? 


ATTENTIONS    TO     THE     WOMAN     AND     CHILD.  397 

be  ruptared,  however  inconsiderable  the  dilatation.  It  is  scarcely  necessary 
to  add  that  an  artificial  rupture  is  only  to  be  resorted  to  when  the  foetus 
shall  be  detected  presenting  by  its  cephalic  extremity ;  for  then  the  dis- 
charge of  a  certain  quantity  of  the  amniotic  liquid,  and  the  retraction  of 
the  uterus,  will  irrevocably  fix  this  part  at  the  upper  strait. 

Again,  according  to  the  majority  of  writers,  the  membranes  maybe  lacer- 
ated before  the  entire  dilatation  of  the  cervix,  where  there  is  reason  to 
suppose  that  the  waters,  from  their  too  great  abundance,  distend  beyond 
measure,  and  thus  Aveaken  the  contraction  of  the  uterine  walls ;  but,  even 
here,  Gardien  recommends  the  greatest  circumspection,  and  advises  the 
previous  employment  of  all  the  measures  calculated  to  stimulate  the  con- 
traction of  the  womb. 

Finally,  we  shall  learn  hereafter  that  the  puncture  of  the  ovum  at  an 
early  period  of  labor,  is  one  of  the  most  effectual  means  of  arresting  certain 
dangerous  hemorrhages  which  may  supervene  during  its  progress. 

The  finger  ought  to  be  introduced  into  the  vagina  several  times  in  the 
course  of  the  last  stage  of  labor,  both  during  the  pains  and  in  the  interval 
between  them,  to  ascertain  the  progress  of  the  head  in  the  excavation. 
Nevertheless,  this  exploration  is  to  be  resorted  to  as  rarely  as  possible,  and 
only  when  the  interest  of  the  mother  seems  to  demand  it. 

Most  women,  supposing  that  they  can  materially  hasten  the  termination 
of  the  labor  by  making  the  most  of  their  pains,  contract  their  muscles,  bear 
down  violently,  and  make  extraordinary  efforts  at  the  beginning ;  but  these 
uselessly  exhaust  their  strength  ;  for,  so  long  as  the  neck  is  ineffaced,  and 
the  bag  of  waters  unbroken,  all  bearing-down  effort  is  fruitless.  But  in 
the  second  stage,  where  the  head  descends  into  the  excavation  and  rests  on 
the  perineum,  she  should  be  encouraged  to  aid  the  uterine  forces  by  a  volun- 
tary contraction  of  the  muscles  of  the  trunk  and  limbs;  though,  as  soon  as 
the  pain  has  passed  off,  all  the  auxiliary  efforts  should  be  at  once  suspended. 
Again,  in  the  latter  moments  of  the  travail,  just  when  the  head  is  about  to 
clear  the  vulva,  the  pains  are  so  sharp  that  the  woman  naturally  gives  Avay 
to  incredible  exertions,  which  may  possibly  occasion  serious  accidents  ; 
hence  all  the  powers  of  persuasion  should  then  be  employed  to  induce  her 
to  moderate  her  strainings. 

During  the  last  moments  of  childbirth,  the  pressure  of  the  head  on  the 
lower  part  of  the  rectum  creates  an  urgent  desire  of  emptying  the  bowels  ; 
and  many  women,  yielding  to  a  misunderstood  modesty,  then  wish  to  rise 
and  retire  to  the  closet;  but  it  would  be  exceedingly  imprudent  to  comply 
with  their  demand,  and  they  must  not  leave  the  bed  under  any  pretext 
whatever.  In  the  first  place,  this  desire  is  often  illusory,  more  especially 
where  the  precaution  has  been  taken  to  empty  the  intestine  at  the  com- 
mencement of  labor;  and  then  it  may  happen,  as  I  once  witnessed,  that  the 
patient,  surprised  by  a  violent  pain,  is  delivered  on  the  close  stool,  without 
the  physician  being  able  in  any  way  to  render  her  the  necessary  attentions. 

It  is  in  these  last  moments  that  the  accoucheur  must  give  all  his  attention 
to  supporting  the  perineum,  which  is  done  by  pressing  the  whole  perineal 
surface  equally,  and  with  a  moderate  degree  of  force,  by  the  palmar  face 
of  the  hand.     The  latter  is  applied   in  such  a  way  as  lo  make  the  radial 


398  LABOR. 

border  of  the  index  finger  cover  the  anterior  margin  of  the  perineum,  the 
ends  of  the  fingers  corresponding  to  the  left  side,  and  the  thenar  eminence 
of  the  palm  to  the  right  side  of  this  partition,  while  the  thumb  is  held  to 
the  right  of  the  labia  externa.  The  pressure  should  be  somewhat  greater 
near  the  anus,  so  as  to  give  the  foetal  head  a  forward  direction,  and  facili- 
tate its  movement  of  extension.     (See  article,  page  680.) 

Finally,  whatever  may  be  the  child's  position,  we  should,  contrary  to  the 
jpinion  of  certain  authors,  abstain  from  introducing  the  fingers  into  the 
lower  part  of  the  vagina,  or  making  pressure  on  the  perineum  and  coccyx; 
in  a  word,  from  performing  what  they  call  their  little  labor.  There  are, 
however,  a  few  measures  which  may  be  useful ;  for  instance,  when  the  geni- 
tal parts  exhibit  great  rigidity,  heat,  and  dryness,  the  emollient  injections, 
or  frictions  with  mild  ointments,  such  as  cerate,  or  cucumber  ointment, 
emollient  fumigations,  or  bathing  in  lukewarm  water,  may  be  very  advan- 
tageous. This  last  remedy,  especially,  is  of  marked  utility  where  the  abdo- 
men is  tender  and  painful,  and  the  cervix  uteri  is  rigid  and  resistant. 

Within  a  few  years,  Professor  Simpson  has  introduced  into  obstetric  prac- 
tice the  use  of  those  anaesthetic  agents,  which  are  daily  productive  of  such 
wonderful  results  in  surgery.  The  Edinburgh  accoucheur  does  not,  how- 
ever, reserve  ether  or  chloroform  for  difficult  cases,  but  advises  their  use  in 
the  most  natural  labors.  The  importance  of  the  subject  demands  of  us  a 
detailed  examination  ;  and  a  long  article  will  be  found  appended,  in  which, 
alter  having  stated  the  known  results,  we  shall  give  frankly  our  own 
opinions. 

Regimen  of  Women  in  Labor.  —  Those  women  whose  labors  are  unusually 
short,  need  not,  as  a  general  rule,  take  any  nourishment  whatever ;  but 
when  the  travail  drags  along,  it  is  necessary  to  sustain  their  strength  by 
articles  of  easy  digestion ;  thus,  as  many  are  in  the  habit  of  taking  coffee 
with  milk  every  morning,  this  may  be  allowed  them  without  danger  ;  and 
then,  during  the  day,  a  few  cupfuls  of  some  broth  may  be  given,  though 
always  in  small  quantities  at  a  time.  Where  the  stomach  is  disordered 
and  vomiting  takes  place,  as  very  frequently  happens,  even  these  liquid 
aliments  will  have  to  be  restricted.  This  plan,  however,  is  not  applicable 
in  all  cases,  since  some  must  be  allowed  what  we  should  refuse  to  others  ; 
for  example,  there  is  no  necessity  for  subjecting  robust  country-women  to 
the  same  severity  of  regimen  as  the  delicate  ladies  of  large  cities.  The 
choice  of  drinks  is  also  a  matter  of  some  importance,  and  we  may  recom- 
mend some  pure  or  sugared  water,  or  a  weak  infusion  of  lime,  or  orange- 
leaves,  of  mallows,  violets,  &c.  Lemonade,  or  wine  diluted  with  water,  will 
be  very  agreeable  to  most  women  at  first ;  but,  in  general,  they  soon  produce 
a  sour  stomach  and  eructations;  all  hot  cordials  and  fermented  liquors 
should  be  positively  prohibited.  In  the  country  districts,  there  is  often 
much  difficulty  in  overcoming  the  vulgar  prejudices  on  this  subject;  but 
the  physician  must  insist  upon  it,  for  he  ought  never  to  lose  sight  of  the 
distress  and  agitation  that  follow  the  administration  of  spirituous  beverages, 
and  which  expose  the  patient  to  inflammations  and  active  hemorrhages. 
Should  it  happen  that  her  feeble  condition  requires  any  restoratives,  then 
some  good  broth,  or  a  little  old  wine,  or  a  few  spoonfuls  <  f  sherry-wine,  arf 
the  only  and  the  best  means  that  can  be  employed. 


ATTENTIONS   TO   THE   WOMAN   AND   CHILD.  399 

ARTICLE   II. 

OF   THE   ATTENTIONS   TO   THE    CHILD    DURING   LABOR. 

Having  determined  the  presentation  and  position,  the  accoucheur  should 
next  ascertain  whether  the  child  is  living  or  dead,  as  it  is  highly  important 
to  determine  this  point,  in  order  to  diminish  his  own  responsibility,  by 
advising  the  family  of  the  fact. 

Before  the  membranes  are  ruptured,  the  diagnosis  may  be  easily  made 
out  by  ascertaining  through  auscultation  the  existence  or  absence  of  the 
pulsations  of  the  foetal  heart,  as  also  the  continuance  or  complete  cessation 
of  the  active  movements,  in  regard  to  which  the  woman  can  always  give 
sufficiently  accurate  information.  After  the  rupture  of  the  membranes,  tLe 
active  movements  are  feeble,  and  sometimes  entirely  absent ;  in  which  case, 
however,  the  pulsations  are  still  detected  by  auscultation. 

The  touch  also  reveals  certain  signs  which  may  shed  still  further  light 
upon  the  question.  Thus,  when  the  child  is  alive  and  the  head  presenting, 
it  often  becomes  affected  with  a  sanguineous  swelling,  the  size  of  which 
depends  upon  the  length  of  time  which  has  elapsed  since  the  discharge  of 
the  waters.  This  tumor  does  not  form  when  the  child  has  ceased  to  live  ; 
and  if  its  death  dates  back  for  several  days,  the  resisting  tumor  foi'med  by 
the  sero-sanguineous  infiltration  will  be  replaced  by  a  soft,  flaccid,  and 
wrinkled  condition  of  the  hairy  scalp.  Besides  this,  the  bones  of  the 
cranium  will  be  more  movable,  and  the  overriding  of  their  edges  greater 
than  usual ;  a  sort  of  crepitation  is  also  produced  by  their  rubbing  against 
each  other.  A  more  embarrassing  case  is  that  in  which  the  child  dies  some 
time  after  the  rupture  of  the  membranes,  but  not  before  the  sanguineous 
tumor  has  had  time  to  be  developed.  Even  here  the  uncertainty  will  be  of 
short  duration,  for,  provided  the  labor  should  continue  beyond  three  or  four 
hours,  the  tumor  will  lose  its  consistency,  and  its  softness  and  flaccidity 
render  a  mistake  a  matter  of  difficulty. 

Finally,  when  the  pelvis  is  rather  contracted,  the  wrinkling  of  the  scalp 
may  simulate  a  swelling,  whose  diagnostic  importance  it  is  well  to  appre- 
ciate. In  this  case,  says  Merriman,  the  best  means  of  judging  of  the  life 
or  death  of  the  child  by  the  tumor  of  the  scalp  is  as  follows :  when  living, 
it  is  observed  that,  at  the  moment  when  the  head  is  strongly  urged  down 
by  the  contraction  of  the  womb,  the  bones  overlap  each  other,  and,  as  a 
consequence,  the  scalp  becomes  folded,  and  thus  constitutes  a  temporary 
tumor;  but  immediately  after  the  pain  is  over,  the  head  regains  its  primi- 
tive form,  by  the  expansion  of  the  cranial  bones,  and  the  folds  and  tume- 
faction previously  exhibited  by  the  skin  disappear,  or,  at  least,  considerably 
diminish.  On  the  contrary,  however,  if  it  be  dead,  the  expansibility  of  the 
bones  is  destroyed,  and  the  head  does  not  reassume  its  primitive  form  and 
volume  after  the  contraction  has  passed  off;  wherefore  the  tumor  formed  by 
the  doubling  of  the  hairy  scalp  still  persists,  in  a  great  measure.  Now,  in 
this  condition  of  affairs,  the  swelling  is  sometimes  greatly  augmented  by  the 
liquids  forced  in  by  the  pressure  from  above,  ami  whenever,  in  such  cases, 
a  perforation  of  the  cranium  has  to  be  resorted  to,  practitioners  well  know 
there  is  half  an  inch  at  least  of  soft  parts  to  be  traversed  before  reaching 
the  bone.     (Merriman's  Synopsis.) 


400  LABOR. 

If  the  face  should  present,  the  softness  of  the  lips,  and  the  flaccidity  ano 
immobility  of  the  tongue,  should  had  us  to  suspect  that  the  child  is  dead  ; 
since,  when  living,  the  firmness  of  all  its  parts,  and  the  motion  of  the  tongue, 
are  often  felt  with  ease. 

In  breech  presentations,  the  introduction  of  the  finger  into  the  anus  will 
detect  a  resistance  and  contractile  power  on  the  part  of  the  sphincter  if  the 
child  be  living,  which  will  be  absent  if  the  child  be  dead. 

Lastly,  in  shoulder  and  arm  presentations,  the  swelling  of  the  member, 
and  its  violet  hue,  will  afford  an  indication  in  favor  of  its  life. 

Should  the  cord  hang  in  the  vagina,  its  softness,  withered  condition,  and 
the  absence  of  pulsation  in  the  umbilical  arteries,  would  justify  a  belief 
that  the  child  was  dead. 

A  thick  and  fetid  condition  of  the  amniotic  fluid,  and  a  discharge  of 
meconium,  have  been  regarded  as  indicating  the  death  of  the  child.  The 
altered  condition  of  the  waters  is  of  no  great  importance,  since  it  has  some- 
times been  found  to  coincide  with  perfect  integrity  of  the  foetal  life,  but  the 
discharge  of  meconium  is  of  greater  significance. 

It  is  not  ac  all  uncommon  to  find  the  meconium  escaping  in  greater  or 
less  quantity  during  parturition  ;  and,  as  previously  stated,  this  peculiarity 
most  frequently  occurs  in  the  positions  of  the  pelvic  extremity,  and  is  then 
of  little  consequence  ;  but  this  does  not  hold  good  in  any  other  presentation  ; 
for  then  its  discharge  is  always  an  unfavorable  sign,  one  calculated  to 
arouse  the  anxious  solicitude  of  the  medical  attendant,  as  it  usually  indi- 
cates a  state  of  suffering  on  the  part  of  the  child,  which  is  almost  always 
due  to  a  compression  of  the  cord.  It  must  be  apparent,  on  the  least  reflec- 
tion upon  the  part  performed  by  the  placenta  during  the  intra-uterine  life, 
that  an  interruption  of  the  foeto-placental  circulation  produces  asphyxia, 
which  latter  determines  a  cerebral  congestion,  and  sometimes  even  an 
apoplectic  effusion,  whence  a  paralysis  of  the  sphincter  ani  results.  Now, 
if  to  this  palsy  of  the  sphincters,  we  add  the  instinctive  acts  of  respiration1 
made  by  the  foetus,  which  are  the  more  violent  as  they  are  the  more  ineffec- 
tual, we  can  understand  without  difficulty  how  an  escape  of  the  meconium 
may  result  from  a  compression  of  the  cord. 

As  regards  the  prognosis,  it  is  important  to  observe  the  precise  moment 
at  which  this  discharge  takes  place,  as  it  is  always  serious  when  it  does  not 
occur  till  some  time  after  the  rupture  of  the  membranes  ;  though  the  waters, 
when  they  escape,  are  often  colored  yellow,  and  the  presence  of  the  meco- 
nium then  is  not  necessarily  an  alarming  symptom.  In  some  cases,  it  may 
indeed  indicate  an  actual  compression  of  the  cord  ;  but  it  may  also  result 
from  a  compression  that  had  existed  some  time  before  birth,  which  may 
have  compromised  the  child's  life  for  a  few  moments,  and  then  have  sud- 
denly disappeared  in  consequence  of  some  brisk  movement  of  the  infant. 

It  is  not  difficult  to  conceive  that  the  cord  might  undergo  a  momentary 
compression  during  the  last  months  of  gestation,  as  also  that  it  might  be 
displaced  by  a  sudden  motion  of  the  child,  and  the  fceto-placental  circula- 
tion be  re-established   in  consequence.     Now,  this  compression  may  have 

1  Mayer  has  observed  respiratory  movements  in  embryos,  even  within  the  ovum,  as 
soon  as  he  compressed  the  cord. 


ATTENTIONS    TO   THE    WOMAN    AND    CHILD.  401 

lasted  so  long  as  to  threaten  asphyxia,  and  consequently  to  prod  ice  a  dis- 
charge of  meconium. 

Endeavors  have  been  made  to  determine  by  the  physical  characters  of 
the  meconium,  whether  its  discharge  was  occasioned  by  a  presentation  of 
the  breech,  or  by  the  sufferings  of  the  foetus.  It  has  been  said  that,  in  the 
latter  case,  the  meconium  is  very  fetid,  thinner,  and  more  diluted,  than 
when  the  breech  is  above  the  uterine  orifice.  Such  signs,  however,  are  very 
inconclusive. 

On  the  whole,  therefore,  a  discharge  of  meconium  in  breech  presentations 
is  of  little  consequence;  but,  in  the  other  presentations,  and  where  occur- 
ring some  time  after  the  rupture  of  the  membranes,  it  is  always  an  unfavor- 
able sign ;  though,  to  judge  of  its  value  at  the  time  of  the  rupture  itself, 
recourse  must  be  had  to  auscultation. 

Of  all  these  signs,  the  best  undoubtedly  is  that  supplied  by  auscultation 
of  the  heart,  whose  pulsations  are  always  perceptible  if  the  child  be  living. 
It  is  quite  possible  for  the  pulsations  of  the  cord  to  escape  detection  even 
though  the  foetus  be  living,  inasmuch  as  they  sometimes  stop  during  the 
pain  and  begin  again  when  it  is  over.  Therefore,  certainty  of  diagnosis 
would  require  that  the  pulsations  should  have  ceased  for  a  considerable 
time,  ten  or  fifteen  minutes  at  the  least. 

In  vertex  presentations,  as  soon  as  the  head  is  expelled  its  disengagement 
is  effected. 

Immediately  after  its  expulsion,  the  disengagement  of  the  head  is  com- 
pleted, either  by  carrying  it  more  and  more  towards  the  pubis,  or  by  insinu- 
ating the  index  upon  one  side  of  the  lower  jaw  ;  this  being  accomplished, 
we  must  next  ascertain  whether  the  cord  does  not  make  one  or  more  turns 
around  the  neck,  and  if  so,  gentle  tractions  must  be  made  on  its  placental 
extremity,  to  avoid  its  being  dragged  upon,  and  to  prevent  strangulation 
of  the  foetus,  &c. ;  and  when  a  sufficient  extent  of  it  cannot  be  brought  out, 
to  render  the  prevention  of  such  accidents  certain,  we  have  to  cut  it,  and 
terminate  the  labor  as  promptly  as  possible,  by  hooking  one  or  the  other 
shoulder  with  the  forefinger.'  After  the  head  is  born,  the  womb,  exhausted 
by  its  last  efforts,  remains  passive  for  some  instants,  and  it  frequently  hap- 
pens that  the  child  begins  to  respire  and  cry,  even  before  the  delivery  of 
the  chest.  We  may,  therefore,  wait  patiently  until  the  contraction  is  re- 
newed, simply  supporting  the  head,  lest  the  mouth  and  nose  be  choked  up 
by  the  cloths  or  blood  found  between  the  woman's  thighs;  but  if  the  atony 
is  prolonged,  and  more  especially  if  the  face  of  the  new-born  infant  is  ob- 
served to  be  red  and  tumefied,  as  sometimes  happens  after  painful  labors, 
the  remainder  of  the  travail  ought  not  to  be  left  entirely  to  nature,  but 
new  pains  should  be  at  once  solicited  by  frictions  over  the  abdominal  walls, 
and  the  patient  be  encouraged  to  bear  down.  The  disengagement  can  al- 
most always  be  accomplished  by  moderate  tractions  upon  the  head  grasped 

1  These  folds  may  occasionally  be  drawn  so  tightly  as  to  strangle  and  kill  the  infant, 
as  occurred  in  the  following  case  :  "Upon  approaching  a  woman  who  had  just  been 
delivered,  I  found  the  child  dead,  and  still  lying  near  the  genital  parts;  the  cord  made 
three  turns  around  its  neck,  and  they  were  so  firmly  tightened  th.it  a  deep  eccliymosifl 
was  seen  on  this  part."  (Guillemot. ) 
26 


4:02  LABOR. 

by  both  hands ;  and  if  these  measures  prove  insufficient,  tne  index  finger, 
curved  like  a  hook,  is  to  be  placed  in  one  of  the  armpits,  and  the  disengage- 
ment of  the  anterior  shoulder  thereby  first  effected. 

After  the  shoulders  are  disengaged,  the  spontaneous  expulsion  of  the 
breech  and  lower  extremities  may  also  be  delayed  in  consequence  of  inac- 
tivity of  the  womb.  Here  again,  it  is  especially  proper  to  endeavor  to  ex- 
cite the  contractions  by  frictions  upon  the  abdomen  ;  but  should  the  life  of 
the  foetus  appear  to  be  in  danger,  the  extraction  should  be  effected  imme- 
diately. 

The  artificial  extraction  of  the  shoulders  or  of  the  lower  part  of  the 
trunk,  we  see,  ought  not  to  be  resorted  to  until  expectation  might  become 
dangerous  to  the  foetus.  When  the  expulsion  is  left  entirely  to  nature,  the 
womb  contracts  in  proportion  as  it  is  emptied,  and  there  is  less  cause  to  fear 
the  consecutive  inertia  which  is  sometimes  produced  by  too  rapid  an  ex- 
traction. 

In  those  rare  cases,  where  the  occiput  remains  posteriorly  until  the  end 
of  labor,  most  accoucheurs  have  recommended  that  an  attempt  should  be 
made  to  bring  it  round  to  the  front,  but  we  doubt  whether  this  will  often 
prove  successful,  although  we  have  never  seen  it  tried,  nor  ever  attempted 
it  ourselves ;  for  we  believe  that  where  the  process  of  rotation  does  not  take 
place  spontaneously,  all  efforts  to  produce  it  artificially  would  be  useless, 
not  to  say  injurious.  Nevertheless,  most  authors  advise,  when  the  head  has 
descended  into  the  excavation,  immediately  after  the  discharge  of  the  waters, 
to  make  it  deviate  either  towards  the  right  or  the  left  in  the  interval  between 
the  contractions  (Velpeau),  by  slipping  two  or  three  fingers  either  along  the 
sacrum,  to  press  the  occiput  forward,  or  else  upon  the  side  of  the  forehead, 
behind  the  pubis,  to  carry  it  backward.  If  we  should  ever  entertain  the 
thought  of  attempting  this  manoeuvre,  we  would  much  prefer  acting  during 
■;he  contraction,  for  then  we  should  only  aid,  without  absolutely  supplanting 
lature ;  we  would  prefer,  whilst  acting  upon  the  occiput,  as  indicated  by 
Velpeau,  applying,  at  the  same  time,  two  fingers  on  the  temples,  and  acting 
thereupon  in  such  a  way  as  to  turn  the  forehead  posteriorly.  But,  we 
repeat,  this  appears  unnecessary  in  the  great  majority  of  cases,  because  it 
only  hastens  the  process  of  rotation,  which  would  have  subsequently  taken 
place  without  it ;  and  even  hurtful  in  others,  for  the  efforts  used  to  bring  it 
about  might  exert  a  pernicious  influence  both  on  the  mother  and  her  child. 

In  fact,  in  ordinary  cases,  where  the  rotation  is  produced  by  the  natural 
powers,  the  trunk  follows  the  movements  of  the  head  ;  but  where  the  latter 
lias  been  turned  by  the  fingers,  the  body  remains  immovable,  and  hence  the 
process  of  forced  rotation  may  dislocate  the  atloido-axoid  articulation  and 
kill  the  child. 

The  oiler  accoucheurs  thought  that  a  spontaneous  delivery,  in  face  pre- 
sentations, was  altogether  impossible,  and  consequently  they  advised  an 
endeavor  to  be  made,  in  the  very  outset  of  labor,  to  convert  them  into  ver- 
tex positions;  but  we  of  the  present  day  understand  better  the  value  of 
such  opinions.  However,  the  rotation  by  which  the  chin  is  brought  under 
the  symphysis  pubis,  whatever  might  have  been  its  primitive  relation  to  the 
superior  strait  (see  Mechanism  of  Delivery  by  the  Face),  is  difficult,  painful, 


ATTENTIONS     TO     THE     WOMAN     AND     CHILD.  403 

and  sometimes,  in  the  mentoposterior  positions,  does  not  take  place  at  all. 
It  will  be  seen,  further  on,  that  the  non-accomplishment  of  this  movement 
forms  one  of  the  most  serious  complications  met  with  in  practice,  and  that 
craniotomy  often  becomes  necessary  in  consequence.  When  the  face  is 
engaged  at  the  inferior  strait,  and  the  chin  is  found  under  the  pubic  arch, 
the  movement  of  flexion  begins,  and  then,  as  has  been  shown,  the  pressure 
to  which  the  vessels  of  the  neck  are  subjected,  during  the  fourth  stage,  may 
retard  the  circulation  enough  to  determine  death  by  cerebral  congestion. 
Hence,  we  learn  what  great  precaution  is  necessary  in  supporting  the  peri- 
neum, since  it  must  be  evident  that  too  great  a  pressure  made  upon  this 
part  would  necessarily  augment  the  compression  of  the  child's  neck. 

The  delivery  by  the  pelvic  extremity  ought  to  be  abandoned  entirely  to 
nature,  unless  there  are  some  unfortunate  complications.  We  have  already 
insisted  upon  this  point  in  the  note  at  page  354 ;  but  do  not  hesitate  to 
repeat  again  the  advice,  not  to  resort  to  any  traction  in  a  natural  labor  by 
the  breech,  because,  as  there  stated,  a  stretching  out  of  the  arms,  and  some- 
times even  an  extension  of  the  head,  result  from  such  imprudent  tractions, 
whilst  these  complications  are  scarcely  ever  met  with  where  the  expulsion 
is  left  to  the  uterine  contractions  entirely.  Now,  there  is  no  difficulty  in 
comprehending  these  different  results,  for  when  the  womb  is  the  sole  agent 
of  the  delivery  of  the  child,  the  latter  is  forcibly  urged  on  by  the  circular 
fibres  at  the  superior  part  of  the  organ,  and  at  the  same  time  is  strongly 
pressed  on  its  sides  by  the  longitudinal  fibres.  The  upper  extremities  are 
therefore  maintained  against  the  lateral  and  anterior  parts  of  the  chest,  the 
head  is  kept  flexed  on  the  thorax,  and  all  these  parts  descend  together ;  but, 
on  the  contrary,  if  any  tractions  are  made,  they  only  act  on  the  trunk[ 
which  then  descends  alone,  while  the  arms,  being  arrested  by  the  margins 
of  the  cervix  uteri,  or  by  the  periphery  of  the  straits,  do  not  participate  in 
the  descent,  and  are  ultimately  found  placed  against  the  sides  of  the  head  ; 
hence,  the  accoucheur's  exclusive  duty  consists  in  receiving  and  supporting 
the  lower  parts  of  the  child  as  they  become  disengaged  ;  taking  care,  as 
soon  as  the  breech  has  cleared  the  vulva,  to  ascertain  the  condition  of  the 
cord.  For  that  purpose,  the  forefinger  is  slipped  up  as  far  as  the  navel, 
when,  if  the  cord  is  found  to  be  tightened  at  its  umbilical  insertion,  he  joins 
the  thumb  to  the  index  so  as  to  produce  some  traction  on  its  placental  ex- 
tremity only,  with  the  view  of  preventing  both  its  being  dragged  upon,  and 
ts  possible  laceration.  The  cord  sometimes  gets  between  the  infant's  thighs; 
ind,  in  such  cases  also,  the  loop  thereby  formed  must  be  enlarged  by  pull- 
ing on  the  placental  extremity,  and  then  by  disengaging  it  from  the  poste- 
rior limb,  bring  it  into  contact  with  the  perineum,  that  is,  with  soft  parts 
whose  compression  will  be  less  severe,  and  consequently  less  dangerous  to 
dhe  circulation  than  what  it  would  sutler  from  the  symphysis  pubis;  but  if 
it  is  too  short  to  be  brought  to  the  exterior,  it  must  be  cut,  and  have  a  liga- 
ture applied  on  its  umbilical  extremity,  and  the  labor  be  terminated^ 
rapidly  as  possible. 

But,  whatever  may  have  been  the  cause,  the  death  of  the  foetus  always 
results  from  the  slowness  with  which  the  shoulders  and  hea  1  are  expelled 
for  it  is  only  during  this  last  part  of  the  travail  that  the  cord  is  compressed, 


404  LABOR. 

jr  that  a  separation  of  the  placenta  takes  place;  hence,  although  we  have 
condemned  all  traction  in  general,  it  must  be  otherwise  under  such  circum- 
stauces.  But  how  is  it  possible  to  determine  the  period  beyond  which  it 
would  be  imprudent  to  wait?  AVe  answer,  that  as  soon  as  asphyxia  comes 
on,  the  suffering  condition  of  the  child  may  easily  be  detected  by  examin- 
ing the  portion  of  the  cord  which  has  been  delivered;  and  if  the  pulsations 
si  ill  maintain  their  intensity,  their  frequency  and  habitual  regularity,  the 
rest  of  the  process  may  be  abandoned  without  danger  to  the  powers  of 
nature  ;  but,  on  the  contrary,  if  they  are  found  to  relax,  or  even  to  become 
more  rapid,  though  at  the  same  time  more  feeble,  threaddike,  and  especially 
if  intermittent  or  irregular,  every  effort  must  be  used  to  remove  the  foetus 
from  the  danger  which  threatens  it. 

The  signs  furnished  by  the  irregularity  of  the  pulsations  of  the  umbilical 
arteries,  and  to  which  great  importance  has  been  attributed  by  some  authors, 
only  become  sensible  after  the  asphyxia  has  lasted  for  so  long  a  time  that 
it  is  not  always  possible  to  overcome  it ;  therefore  we  regard  as  much 
more  available  the  phenomena  next  to  be  mentioned. 

When  the  head  alone  remains  behind  in  the  pelvic  excavation,  the  child 
is  very  often  observed  to  dilate  its  chest  actively,  and  make  a  violent  inspi- 
ratory effort,  which  may  be  referred  to  a  rapid  convulsive  contraction  of  the 
diaphragm  and  abdominal  muscles,  repeated  at  irregular  intervals;  now 
such  acts  never  take  place  while  the  feeto-placental  circulation  remains 
intact,  since  the  pulmonary  respiration  is  unnecessary  so  long  as  the  pla- 
cental one  is  going  on,  and  therefore  these  struggles  constantly  announce  a 
state  of  suffering,  or  of  imminent  asphyxia,  from  which  the  infant  must 
speedily  be  relieved.  Where  the  head  alone  is  undelivered,  the  patient 
must  be  encouraged  to  bear  down  strongly,  so  as  to  hasten  the  termination 
of  her  labor,  and  avoid  a  prolonged  compression  of  the  cord ;  and  the 
accoucheur  might  facilitate  the  flexion  of  the  head  by  gently  carrying  the 
trunk  up  in  front  of  the  symphysis,  or  when  the  flexion  appears  difficult, 
he  may,  by  insinuating  two  fingers  under  the  symphysis,  press  slightly  on 
the  occiput  ;  for  a  comparatively  light  force  exercised  on  the  posterior  part 
of  the  head  is  often  sufficient  to  reverse  the  great  occipito-mental  diameter, 
and  terminate  the  delivery.  Should  the  head  resist  these  efforts,  other 
measures  become  necessary ;  but  they  belong  to  instrumental  delivery,  and 
we  shall  treat  of  them  in  the  article  on  Version. 

Finally,  should  it  be  impossible  to  extract  the  head  immediately,  Ave  may 
endeavor  to  introduce  the  fore  and  middle  fingers  into  the  mouth  of  the 
child,  and  then  separate  them  slightly,  so  as  to  leave  an  open  space  through 
which  air  might  find  its  way  to  the  mouth.  The  same  object  would  be 
effected  with  still  greater  certainty,  by  introducing  a  large  catheter  into 
the  mouth. 


ATTENTIONS   TO   THE    WOMA2J    AND   CHILD.  405 


CHAPTER    VIII. 

OF    THE    ATTENTIONS    TO    THE    WOMAN    AND    CHILD    IMMEDIATELY 
AFTER    DELIVERY. 

ARTICLE    I. 

OK  THE  ATTENTIONS  TO  THE  WOMAN  IMMEDIATELY  AFTER  DELIVERY. 

As  soon  as  the  child  has  been  expelled,  the  accoucheur  should  place  "his 
hand  upon  the  mother's  abdomen  in  order  to  ascertain  -whether  there  is 
another  child,  as  also  to  learn  whether  the  uterus  contracts  well,  inasmuch 
as  inertia  of  the  organ  should  lead  to  the  anticipation  of  hemorrhage.  It 
would  also  be  right  to  determine  whether  there  be  too  free  a  discharge  of 
blood  from  the  external  parts. 

The  expulsion  of  the  placenta  and  its  annexes,  whether  spontaneous  or 
assisted  by  the  accoucheur,  generally  follows  very  shortly  after  the  exit  of 
the  foetus.  In  order  to  avoid  separating  the  study  of  this  natural  delivery 
of  the  after-birth  from  that  of  the  difficulties  and  dangers  which  may  attend 
it,  we  shall  treat  of  them  separately.     (See  Delivery  of  the  After-birth.) 

After  the  delivery,  the  accoucheur  should  ascertain,  both  by  the  external 
examination  and  the  vaginal  touch,  whether  the  placenta  has  drawn  down 
or  inverted  the  fundus  of  the  womb,  for  the  purpose  of  rectifying  it  at  once 
if  such  an  accident  has  occurred.  If  everything  proves  to  be  in  its  natural 
condition,  frictions  with  the  hand  are  to  be  made  over  the  hypogastric  region 
from  time  to  time,  in  order  to  excite  the  retraction  of  the  uterus,  and  thus 
favor  its  disengorgement,  and  the  expulsion  of  the  coagula  which  may  be 
still  contained  there.  The  patient  is  allowed  to  remain  for  some  minutes 
on  the  bed  where  she  was  delivered,  so  as  to  give  her  a  little  repose,  as  well 
as  time  to  the  uterus  and  vagina  to  clear  themselves  of  the  blood,  which 
flows  at  first  in  abundance,  and  would  soil  the  linen  in  which  she  is  about 
to  be  enveloped.  Besides,  a  fewr  minutes  are  ordinarily  devoted  to  paying 
those  necessary  attentions  to  the  infant,  hereafter  pointed  out.  In  fact,  she 
might  remain  upon  the  same  bed  a  still  longer  period,  when  the  delivery 
has  either  been  preceded  or  followed  by  syncope,  hemorrhage,  or  any  other 
accident,  or  even  where  there  is  reason  to  fear  something  of  this  nature, 
taking  care,  however,  to  substitute  dry  things  for  those  that  have  been 
soiled.  She  ought  to  lie  perfectly  flat,  the  thighs  stretched  out  alongside 
of  each  other,  lightly  covered,  and  be  left  in  silence,  and  the  most  absolute 
rest  of  both  body  and  mind.  In  about  half  an  hour,  the  patient  will  again 
require  special  attention  ;  the  genital  organs,  and  upper  part  of  the  thighs, 
are  to  be  first  washed  carefully  and  gently  with  lukewarm  water,  pure  or 
mixed  with  a  little  wine;  then  they  are  to  be  wiped  with  warm  and  well- 
dried  towels,  and  all  the  garments  worn  (luring  parturition  that  have  been 
eoiled  by  the  perspiration,  discharges,  and  fecal  matters,  are  removed,  and 
replaced  by  others,  previously  well  dried  and  wanned  ;  their  shape  is  unim- 
portant, the  only  point  requisite  is  to  have  them  large  enough  not  to 
incommode  the  woman   in  any  way,  and  to  admit  of  being  changed   easily 


406  LABOR. 

and  promptly.  The  greatest  celerity  is  to  be  used  in  this  toiht,  lest  she 
should  be  long  exposed  to  the  air  ;  the  arms  and  breast  particularly  ought 
to  be  well  clothed,  so  that  the  patient  may,  .luring  the  day  at  least,  keep 
them  out  of  bed  without  danger  of  taking  cold. 

All  these  preparations  being  completed,  she  is  next  to  be  transferred  to 
the  bed  intended  for  her  reception  during  the  lying-in.  Many  females, 
finding  themselves  well  enough,  want  to  walk  across  to  the  permanent  bed ; 
but  against  such  an  imprudence  the  physician  must  interpose  the  whole 
weight  of  his  authority.  The  one  to  which  she  is  to  be  transported  must  be 
previously  warmed,  and  provided  with  a  sufficient  amount  of  covering  that 
.an  easily  be  changed  ;  though  the  coverlets  should  not  be  thicker  or  more 
numerous  than  those  used  before  pregnancy. 

There  is  a  custom  much  in  vogue  of  surrounding  the  belly  with  a  moder- 
ately tightened  bandage;  and  the  women,  for  the  most  part,  attach  the 
highest  importance  to  this  measure  as  a  preservative  against  the  wrinkles 
and  folds  that  are  found  after  labor  on  the  skin  of  the  abdomen,  as  also  to 
prevent  the  latter  from  remaining  too  voluminous.  Their  desires  may  be 
yielded  to  the  more  willingly,  as  such  a  bandage,  when  moderately  drawn, 
supplies  the  pressure  no  longer  afforded  by  the  abdominal  walls,  and  thereby 
prevents  the  afflux  and  stasis  of  the  fluids,  the  engorgement  of  the  uterine 
walls,  and  the  dilatation  of  the  cavity  of  this  viscus;  and  it  has  the  further 
advantage  of  obviating  the  tendency  to  syncope,  and  of  diminishing  the 
after-pains.  But,  in  order  to  obtain  all  these  benefits,  it  should  be  large 
enough  to  compress  the  whole  sub-umbilical  region  equally.  Care  should 
be  taken  to  prevent  its  becoming  doubled  up,  whereby  a  circular  cord  is 
formed,  which,  from  opposing  the  ready  return  of  the  fluids,  would  then 
prove  a  cause  of  hemorrhage. 

The  body  bandage  may  he  substituted  with  advantage  by  a  folded  cloth 
applied  fiat  upon  the  abdomen  which  it  compresses  gently  by  its  weight, 
which  is  sufficient  for  the  purpose. 

Smuic  women,  influenced  by  a  feeling  of  coquetry,  also  desire  to  (ompress 
their  mammae  by  means  of  a  bandage,  with  a  view  of  preventing  their  en- 
largement, and  their  consequent  softness  and  flaccidity,  and  some  even  go 
so  far  as  to  apply  topical  astringents  for  the  purpose  of  obviating  an  over- 
abundant secretion  of  milk ;  but  such  measures  should  be  proscribed  in  the 
most  absolute  manner,  since  they  might  prove  very  dangerous.  These 
organs  only  require  a  sufficient  amount  of  covering  to  protect  them  from 
the  contact  of  the  external  air,  and  to  maintain  a  proper  degree  of  heat. 

ARTICLE   II. 

OF   THE   ATTENTIONS    TO    THE    CHILD    IMMEDIATELY    AFTER    ITS    BIRTH. 

The  management  of  the  new-born  infant  necessarily  varies  according  to 
whether  it  is  strong,  vigorous,  and  healthy;  or  whether,  on  the  other  hand, 
it  is  born  in  a  state  of  debility  or  disease. 

§  1.  Of  the  Child  in  a  Healthy  State. 

When  the  child  escapes  from  its  mother's  womb  living,  and  in  a  healthy 
utate,  the  circulati existing  between  it  and  the  placenta  is  observed  to 


ATTENTIONS    TO    THE    WOMAN    AND    CHILD.  407 

continue  for  some  time,  where  the  delivery  is  abandoned  entirely  to  the 
powers  of  nature;  the  after-birth  is  soon  detached  and  expelled,  and  then  it 
as  well  as  the  cord  loses  its  vitality,  the  circulation  becomes  weaker  and 
weaker,  and  the  pulsations  in  the  arteries  gradually  cease,  commencing  at 
their  placental  extremity;  and  some  authors  have  advised  this  event  to  be 
waited  for  before  cutting  the  cord;  but  as  this  spontaneous  delivery  most 
generally  requires  a  long  time,  it  is  customary  to  make  the  section  irame 
diately  after  its  birth,  and  then  the  following  attentions  to  the  new  beirg 
become  necessary,  namely  :  where  the  infant  is  entirely  clear  of  the  mothei  's 
parts,  the  cord  is  disengaged  if  it  had  been  twisted  around  its  neck  or  body. 
and  the  child  is  placed  on  the  side,  having  its  face  turned  away  from  the 
vulva,  so  that  it  may  breathe  freely  without  running  the  risk  of  being 
suffocated  by  the  liquids  that  escape  from  the  vagina.  The  umbilical  cord 
is  next  cut  at  about  five  or  six  fingers'  breadth  from  the  abdomen,  generally 
using  the  scissors  for  this  operation,  though  it  may  be  done  with  any  cutting 
instrument  whatever.  As  soon  as  the  section  is  effected,  the  cut  extremity 
is  slightly  pinched  between  the  thumb  and  forefinger,  while  the  remaining 
three  fingers  grasp  the  breech,  and  the  other  hand  is  placed  under  the 
shoulders  and  neck  of  the  child,  which  is  thus  lifted  out  of  the  bed,  and 
placed  on  the  nurse's  knees  prepared  for  its  reception.  It  may  then  be 
examined  more  at  leisure,  to  ascertain  that  no  loop  of  intestine  exists  at  the 
base  of  the  cord,  and  to  permit  the  latter  to  bleed  if  judged  advisable, 
before  applying  the  ligature.  A  ribbon,  eight  or  ten  inches  long,  may  be 
used  for  this  latter  purpose,  or  a  cord  consisting  of  a  skein  of  coarse  thread  ; 
but,  before  applying  it,  the  gut  is  to  be  reduced  if  there  is  an  umbilical 
hernia,  and  then  it  ought  to  be  tied  at  about  two,  three,  or  four  inches  from 
the  surface  of  the  abdomen;  the  only  precaution  requisite  is  to  avoid  placing 
it  around  the  skin,  which  is  prolonged  more  or  less  upon  the  cord  ;  for  pain, 
inflammation,  and  ulceration  would  thereby  result,  the  subsequent  cure  of 
which  might  be  attended  with  some  difficulty.  As  a  general  rule,  it  is  best 
to  leave  sufficient  space  between  the  ligature  and  the  fold  of  the  skin,  to 
allow  of  the  application  of  a  second,  should  the  first  prove  insufficient.  The 
ligature  must  be  drawn  tight  enough  to  obliterate  the  arteries  completely  and 
permanently,  without  cutting  their  coats.  If  the  cord  happens  to  be  thick 
and  infiltrated,  the  ligature  will  strangle  its  vessels  but  very  imperfectly  : 
and  when  it  afterwards  becomes  diminished  by  the  escape  or  evaporation 
of  the  fluid  parts,  the  vessels  being  no  longer  compressed,  will  obviously 
permit  a  free  discharge  of  blood  from  the  cut  end.  Besides,  the  putrefying 
of  the  lymph  will  soon  produce  a  very  fetid  smell,  and  irritate  the  skin 
wherever  it  comes  in  contact;  and  it  is  therefore,  to  prevent  such  accidents, 
that  authors  very  properly  recommend  the  expression  of  this  viscid  fluid  by 
pressing  and  slipping  the  cord  between  the  fingers,  and  even  by  pricking  its 
enveloping  membrane,  taking  care,  however,  to  avoid  wounding  its  vessel-; 
and  lastly,  if  the  cord  were  unusually  huge,  it  might,  for  greater  security,  be 
bent  backward  after  the  first  knot  was  tied,  and  be  included  in  a  second  one. 
Where  there  is  reason  to  suspect  a  twin  pregnancy,  it  is  necessary  after  cutting 
the  cord  of  the  first-born  to  apply  a  ligature  around  its  placental  extremity 
also.      Though  the  application  of  the  second  ligature  i>,  in  most  eases,  a  use- 


408  LABOR. 

less  precaution,  yet  the  feet  that  in  some  very  exceptional  cases  in  which  a 
communication  exists  between  the  vascular  ramifications  of 'die  two  placentas, 
it  might  prevent  a  hemorrhage  which  would  quickly  prove  Jatal  to  the  second 
child,  is  sufficient  reason  for  never  dispensing  with  it. 

Numerous  discussions  have  sprung  up  as  to  whether  the  ligature  of  the 
umbilical  cord  was  absolutely  indispensable,  and.  if  so,  whether  it  should 
he  applied  prior  to  the  section,  or  whether  the  cord  might  he  cut  before  it 
is  tied.  Now,  although  it  is  highly  probable  that  the  circulation  in  the 
umbilical  vessels  would  be  arrested  spontaneously,  after  the  regular  estab- 
lishment of  the  respiration  ;  as,  also,  that  the  ligature  is  almost  or  entirely 
3S  in  the  great  majority  of  cases,  yet,  if  it  is  certain  that  a  hemorrhage 
has  taken  place  in  some  few,  even  though  they  be  exceptional  instances, 
from  the  cord  having  been  imperfectly  tied,  or  else  not  ligated  at  all  ;  this, 
of  itself,  is  a  sufficient  reason  for  not  neglecting  so  simple  a  precaution ;  and 
as  to  the  second  question,  the  course  just  pointed  out  is,  in  our  opinion,  de- 
cidedly preferable. 

The  surface  of  the  child's  body  is  next  to  be  cleansed  of  the  ceruminous 
Bubstance  that  covers  it,  and  from  the  blood  and  other  matters  which  be- 
come attached  at  the  moment  of  delivery ;  but  as  this  can  scarcely  be  re- 
moved by  a  simple  rubbing  with  dry  towels,  it  should  first  be  diluted  with 
a  little  oil,  or  fresh  butter,  and  then  be  gently  wiped  off;  the  yolk  of  an 
egg  would  produce  the  same  effect,  and  besides,  would  render  this  matter 
more  miscible  with  water.  To  get  rid  of  the  blood  and  other  impurities, 
water  mingled  with  wine,  or  else  a  simple  bath,  into  which  the  child  is 
plunged,  is  most  generally  employed  ;  the  temperature  of  the  bath  should 
he  about  twenty-five  degrees  (77°  Fahr.). 

The  infant  being  well  washed,  sponged,  and  wiped,  is  next  to  be  dressed  ; 
hut,  hefore  doing  so,  the  physician  himself  should  first  envelop  the  cord  in 
a  compress  intended  for  that  purpose;  which  compress  is  merely  a  piece  of 
fine  linen,  of  a  square  shape,  and  having  an  opening  at  its  centre  large 
enough  to  allow  the  cord  to  pass  through  it  easily,  and  then,  after  having 
ripped  one  of  its  sides  from  the  free  margin  lown  to  this  hole,  the  root  of 
the  cord  is  lodged  at  the  bottom  of  the  resulting  fissure;  then  the  uncut 
pari  of  this  little  compress  remains  below,  and  the  two  halves  of  the  divided 
portion  are  turned  over  and  crossed  in  front  of  the  cord,  the  whole  being 
placed  at  the  upper  and  left  side  of  the  abdomen.  A  second  soft  and  square 
compress  covers  the  first,  and  a  band  three  or  four  fingers'  breadth  wide, 
and  Ion--  enough  to  go  twice  round  the  body,  supports  the  whole  of  the  little 
apparatus  in  this  position. 

Before  enveloping  the  cord,  the  dressing  of  the  child  had  already  com- 
menced,  it-  head,  arms,  and  chest  being  then  covered.  The  rest  of  its 
clothing  should  he  warm,  .-oft,  and  modeiately  tight.  In  France,  it  consists 
of  a  camisole,  or  little  woollen  jacket,  furnished  with  a  soft  chemisette  that 
h  fastened  behind  by  pins,  then  one  of  linen,  and  another  of  wool  or  cotton. 
The  English  envelop  their  children  in  a  long,  loose  robe,  or  something  like 
a  flannel   sack. 

Befom  dressing  the  child,  the  physician  should  ascertain  whether  it  is 
Affected  with  any  malformation  ;  and  during  the  three  or  four  days  following 


ATTENTIONS    TO    THE    WOMAN    AND    CHILD.  409 

its  birth,  he  ought  carefully  to  watch  over  the  excretion  of  urine  and  of 
meconium  (for  the  expulsion  of  the  latter  is  sometimes  delayed  for  that 
length  of  time),  and  to  facilitate  it  by  plunging  it  into  a  tepid  bath,  when 
he  is  certain  the  infant  is  well  formed.  The  prolonged  retention  of  the 
meconium  is  also  an  indication  for  the  employment  of  some  mild  laxative, 
such  as  whey,  the  syrup  of  violets,  the  oil  of  sweet  almonds,  or  manna  ;  the 
compound  syrup  of  succory  is  also  very  generally  used,  or  the  compound 
syrup  of  rhubarb,  either  alone  or  mixed  with  sweet  almond-oil,  in  the  quan- 
tity of  two  drachms  or  half  an  ounce  in  the  course  of  the  day.  Some  per- 
sons administer  these  gentle  remedies  to  all  children  without  distinction, 
more  especially  to  those  that  are  wet-nursed,  for  the  purpose  of  supplying, 
they  say,  the  place  of  the  colostrum,  or  first  maternal  milk,  whose  slightly 
purgative  action  clears  out  the  intestinal  canal ;  but  the  warm  water  and 
sugar  ordinarily  given  to  the  child  as  nourishment  on  the  first  day,  is  usually 
quite  sufficient  to  facilitate  the  expulsion  of  the  meconium,  and  the  viscid 
fluids  that  sometimes  obstruct  the  fauces  and  stomach. 


§  2.  Of  the  Child  in  a  Feeble  or  Diseased  State. 

The  ordinary  attentions  to  the  child,  when  born  in  a  healthy  condition, 
have  just  been  described  ;  but  it  not  unfrequently  happens  that  the  infant, 
at  the  moment  of  its  birth,  is  in  a  state  of  great  debility,  or  even  of  apparent 
death,  which  would  soon  be  followed  by  a  real  one,  if  adequate  measures 
were  not  resorted  to  at  once  to  prevent  it.  This  apparent  death  shows  itself 
under  two  widely  different  aspects,  which  have  been  described  by  most 
authors  as  the  apoplexy  and  the  asphyxia  of  new-born  children.  Many 
English  and  German  accoucheurs  have  for  a  long  time  rejected  these  deno- 
minations, as  characterizing  but  imperfectly  the  pathological  conditions  to 
which  they  were  applied  ;  and  M.  P.  Dubois,  in  a  more  recent  article,  after 
having  remarked  that  the  most  constant  anatomical  character  of  apoplexy 
in  the  adult  is  wanting  in  what  has  been  called  the  apoplexy  of  the  child, 
and  that  wide  differences  also  exist  between  the  symptoms  of  asphyxia  in 
grown  persons,  and  those  of  the  asphyxiated  state  of  the  new-horn  infant, 
likewise  concludes  that  the  same  name  has  been  improperly  applied  to  such 
dissimilar  conditions  ;  and  consequently  he,  like  M.  Nsegele,  designates  that 
state  of  the  child  in  which  no  sign  of  life  is  observed,  and  none  of  those  of 
death  is  recognized,  under  the  title  of  apparent  death. 

Both  terms  of  this  definition  are  evidently  contradictory,  since  death  is 
characterized  by  an.entire  absence  of  the  signs  of  life.  For  our  own  part, 
we  regard  apparent  death  as  a  state  in  which,  notwithstanding  the  abolition 
of  the  actions  of  animal  life,  some  at  least  of  the  functions  of  organic  life 
continue,  and,  of  necessity,  the  pulsations  of  the  hear!. 

Now,  in  carefully  examining  the  symptoms  of  the  child's  apparent  death, 
it  is  found  that  it  is  sometimes  characterized  by  a  vivid  redness  of  the  face 
and  upper  part  of  the  body,  by  a  prominence  and  injection  of  the  eyeball, 
and  a  swelling  of  the  countenance,  the  skin  of  which  is  dotted  here  and 
there  with  bluish  spots;  while  at  others,  we  are  struck  with  the  discoloration 


410  LABOR. 

in  the  skin,  and  the  flabbiness  of  the  flesh.  In  the  foiraer  case,  the  head  is 
swollen  and  very  warm,  the  lips  are  tumefied  and  of  a  deep-blue  color;  tne 
eyes  start  from  the  head,  and  the  tongue  adheres  to  the  roof  of  the  mouth; 
the  head  is  often  elongated,  hard,  and  the  features  slightly  swollen;  the  pul- 
sations of  the  heart,  though  sometimes  quite  strong  and  distinct,  are  at  other? 
obscure  and  feeble;  occasionally  the  umbilical  cord  is  distended  with  blood. 

In  the  second,  the  child  exhibits  a  mortal  pallor;  its  limbs  are  pendent 
and  flabby  ;  the  akin  is  discolored,  and  is  often  soiled  by  the  meconium  ;  the 
lips  are  pale;  the  lower  jaw  hangs  down,  and  the  umbilical  cord  and  heart 
either  do  not  palpitate  at  all,  or  but  very  feebly.  An  infant,  in  this  condi- 
tion, often  moves  at  the  moment  of  birth  and  cries,  but  soon  falls  back  again 
in  a  state  of  apparent  death. 

These  diversities  in  the  physical  characters  of  children  born  in  a  state  of 
apparent  death,  may  be  occasioned,  doubtless,  by  various  causes,  though  they 
are  also  often  due,  simply,  to  a  greater  or  less  advanced  condition  of  the 
same  pathological  state ;  hence  it  is  wrong  to  regard  them  as  the  charac- 
teristic signs  of  quite  dissimilar  lesions.  Therefore,  although  I  am  convinced 
that  they  sometimes  furnish  indications  for  very  different  kinds  of  treatment, 
and  thai  under  this  point  of  view  it  is  important  to  observe  them  carefully, 
I  cannol  regard  them  as  affording  a  basis  for  nosological  distinctions  which 
it  is  impossible  to  justify.  As  the  expression  apparent  death  presupposes 
nothing  in  regard  to  the  nature  and  cause  of  that  state,  it  deserves  on  that 
very  account  to  be  retained. 

That  what  we  are  about  to  state  respecting  the  apparent  death  of  new- 
born children  may  be  the  better  understood,  we  shall  give,  first,  a  brief  ex- 
position of  the  mechanism  by  which  respiration  is  established  immediately 
after  birth. 

All  physiologists  admit,  that  the  medulla  oblongata  is  the  centre  and 
regulator  of  the  respiratory  movements  of  the  adult.  From  it  also  is  sent 
forth  the  motor  impulse  which  gives  rise  to  the  first  act  of  inspiration. 

Marshall  Hall  has  endeavored  to  prove,  experimentally,  that  the  first  in- 
spiration is  the  result  of  a  reflex  action,1  produced  by  the  excitement  of  the 
nerves  of  the  surface  of  the  body,  especially  of  the  trifacial,  by  the  contact 
of  the  external  air,  and  that  the  respiration,  when  once  established,  is  sus- 
tained through  the  influence  of  the  reflex  action  due  to  the  irritation  of  the 
pneumogastric  nerves  by  the  contact  of  the  air  introduced  into  the  lungs. 

1  An  impression  made  upon  our  organs  may  give  rise  to  movements  of  different  char- 
acters, by  pursuing  different  routes  to  the  cerebro-spinal  axis.  Thus,  sometimes, 
when  transmitted  directly  to  the  encephalon  by  the  sensitive  nerves  of  the  cranium, 
or  indirectly  through  the  nerves  of  the  spinal  marrow,  it  is  transformed  into  a  sensa- 
tion in  th.it  pari  of  the  encephalon  in  which  the  sensorium  commune  is  situated,  and 
consequently  reaches  the  consciousness  of  the  animal,  who  is  then  capable  of  reacting 
by  voluntary  movements.  Sometimes,  also,  it  is  transmitted  bythe  nerves  of  sensation 
cither  to  the  encephalon  or  to  the  spinal  marrow,  which  impression,  without  neces- 
sarily being  transformed  into  a  sensation,  may  produce  an  excitement  which  is  imme- 
diately reflected  upon  the  motor  nerves,  and  gives  rise  to  the  so-called  reflex  move- 
ments, in  the  production  of  which  the  will  has  no  part  whatever. 

The  power  which  tint--  gives  rise  to  movements  without  the  participation  of  the  will, 
has  been  regarded  as  a  special  endowment  of  the  cerebro-spinal  axis,  and  has  been 
designated  as  the  r,jL\c  poi*tr,  faculty,  or  propria. 


ATTENTIONS    TO    THE    WOMAN    AND    CHILD.  411 

The  same  physiologist  also  holds  that  the  respiratory  movements  may  take 
place  under  the  influence  of  other  causes;  such,  for  example,  as  the  impres- 
sion produced  upon  the  medulla  oblongata  by  a  great  loss  of  blood,  as  also 
the  excitement  which  it  undergoes  from  the  contact  of  venous  blood.  Intc 
the  latter  category  enter  all  the  respiratory  movements  of  incomplete  as- 
phyxia. 

In  normal  cases,  the  foetus,  having  in  no  wise  suffered  during  the  labor, 
retains  its  cutaneous  sensibility  intact,  and  the  irritation  produced  by  tin. 
contact  of  the  air  with  the  cutaneous  nerves  is  transmitted  to  the  medulla 
oblongata,  which,  acting  in  its  turn  upon  the  respiratory  nerves,  produces 
the  movements  of  respiration. 

But  should  it  happen  that  the  foetus  from  the  moment  of  birth  has  been 
deprived  for  a  certain  time  of  those  means  of  respiration  which  it  finds  in 
the  placenta,  or  that,  the  latter  being  separated  immediately  after  the  child 
is  expelled,  any  obstacle  should  arise  to  the  introduction  of  air  into  the 
bronchia,  there  would  be,  in  both  cases,  a  commencement  of  asphyxia.  The 
contact  of  the  non-oxygenated  blood  would  irritate  the  medulla  oblongata, 
and  this  irritation  being  transmitted  to  the  inspiratory  nerves,  may  also  give 
rise  to  respiratory  movements  of  the  muscles  of  the  face,  breast,  and  abdo- 
men, and  produce,  in  short,  the  first  inspiration.1  The  central  motor  im- 
pulse would  soon  be  substituted  by  the  reflex  action  of  the  ramifications  of 
the  pneumogastric  nerves,  which  are  irritated  by  the  air  introduced  into  the 
lungs,  and  the  respiration  would  continue  under  its  influence. 

When  the  foetus  is  threatened  with  asphyxia  in  the  latter  stages  of  preg 
nancy  or  during  labor,  in  consequence  of  compression  of  the  cord  or  separa- 
tion of  the  placenta,  its  death  is  preceded  by  convulsive  movements  and 
efforts  to  breathe ;  then  the  mothers  tell  us,  that  the  child,  after  having 
moved  actively,  suddenly  became  quiet ;  and  Beclard  saw  a  foetus  inclosed 
in  the  unruptured  membranes  make  inspiratory  movements,  and  breathe 
water  instead  of  air.  It  is  for  this  reason,  also,  that  in  certain  positions  of 
the  face  the  child  has  been  enabled  to  respire,  although  still  inclosed  in  its 
mother's  womb ;  and  the  uterine  vagitus,  which  always  supposes  a  previous 
inspiration,  can  be  explained  in  no  other  manner.  In  all  these  cases,  in  fact, 
the  non-oxygenated  blood  acts  as  an  irritant  to  the  medulla  oblongata,  which 
transmits  the  irritation  in  its  turn  to  the  nerves  of  inspiration.  Nothing  can 
be  claimed  here  for  reflex  action. 

We  must  be  careful,  however,  not  to  confound  these  two  excitors  of  the 
inspiratory  act.  The  first  is  the  natural  excitant,  whilst  the  other  is  always 
pathological,  and  only  intended  to  replace  the  normal  stimulus.     Now,  every 

1  Marshall  Hall  removed  the  brain  of  a  kitten,  cut  the  pneu gastric  nerves,  and 

opened  the  trachea.  He  found  the  respiration  to  become  slower,  though  it  continued 
with  regularity.  When  he  Btopped  the  opening  in  the  trachea,  the  Bcene  changed  im- 
mediately; the  animal  opened  its  mouth  widely,  made  violent  inspiratory  efforts,  and 

was  affected  with  some  movements  of  a  convulsive  character.  When  the  trachea  was 
reopened,  the  respiration  became  as  regular  as  before,  and  when  closed  again,  the 
symptoms  of  asphyxia  reappeared;  in  both  these  cases,  the  central  organ,  or  the  me- 
dulla oblongata,  was  evidently  the  source  of  the  respiratory  impulse:  since  the  .lest  ruc- 
tion of  the  brain  and  the  section  of  the  pneumogastric  nerves  rendered  all  reflex  action 
impossible. 


412  LABOR. 

pathological  act  is  but  an  effort  to  accomplish  some  physiological  pi.ieess, 
ivhich  has  become  difficult  or  imjiossible ;  and  though  it  may  in  some  cases 
restore  life  to  a  child,  it  is  likely,  in  many  others,  to  prove  insufficient. 

it  very  often  happens  that  a  child  born  in  a  semi-asphyxiated  condition, 
in  consequence  of  a  difficult  labor,  makes  a  few  sudden  and  violent  inspiratory 
movements,  but  would  nevertheless  succumb  rapidly,  were  not  the  reflex 
action  called  into  play,  and  did  it  not  soon  replace  completely  the  patholo- 
gical excitant,  which,  just  before,  had  acted  alone  upon  the  spinal  marrow. 
As  the  skin,  in  this  state  of  diminished  sensibility,  is  no  longer  stimulated 
sufficiently  by  the  external  air,  special  means  should  be  resorted  to  whilst 
there  is  yet  time  to  arouse  the  excito-motor  action  of  the  cutaneous  nerves, 
and  provided  the  asphyxia  has  not  gone  too  far,  they  will  often  be  crowned 
with  success.  But  if  the  child  is  small  and  feeble,  or  if  the  causes  of  the 
asphyxia  have  acted  for  too  long  a  time,  the  contractions  of  the  inspiratory 
muscles  are  feeble  and  distant,  and  soon  cease  entirely;  the  heart,  too,  ceases 
to  beat,  and  the  child  dies.  Though,  whilst  the  heart  is  still  beating,  we 
may  succeed  in  exciting  the  reflex  action  of  the  muscles  of  inspiration,  to  the 
extent  of  producing  a  sudden  inspiratory  movement  after  every  excitation, 
the  symptoms  of  asphyxia  remaining,  however,  unchanged,  the  child  will  die 
in  spite  of  all  that  can  be  done. 

If  it  be  true  that  the  impression  produced  by  the  external  cold  upon  the 
skin  of  the  body  and  face,  is  the  first  and  only  cause  of  the  reflex  action  of 
the  medulla  oblongata  upon  the  nerves  of  inspiration,  and  thus  produces  the 
first  inspiratory  art,  we  can  readily  understand  that  everything  calculated 
to  diminish  notably  or  to  destroy  the  cutaneous  sensibility,  will  retard,  or 
even  render  impossible,  the  first  inspiratory  effort,  and  reduce  the  foetus  to  a 
state  of  apparent  death.  The  causes  of  the  latter  are,  therefore,  such  as 
paralyze  to  a  greater  or  less  extent  the  nervous  centres,  whose  influence, 
though  completely  foreign  to  the  maintenance  of  foetal  life,  becomes  indis- 
pensable to  the  establishment  and  continuance  of  extra-uterine  existence. 

Now,  these  causes  are  quite  numerous;  and,  with  the  exception  of  a  few, 
exert  their  destructive  influence  during  the  latter  periods  of  labor.  They 
may  be  divided  into:  1,  lesions  of  respiration;  2,  lesions  of  circulation;  3, 
lesions  of  the  nervous  centres.  The  first  are  capable  of  producing  various 
degrees  of  asphyxia;  the  second  may  give  rise  to  a  fatal  hemorrhage  as 
regards  the  child ;  the  third  affect  the  nervous  centres  directly,  and  render 
them  incapable  of  performing  the  functions  to  which  they  are  destined 
immediately  after  birth. 

1.  Lesion*  of  tin  Respiration. —  These  are  occasioned  by  everything  which 
obstructs  the  respiration.  Thus,  there  have  been  pointed  out  as  occurring 
during  labor,  the  compression  of  the  umbilical  cord  between  the  sides  of  the 
pelvis  and  the  head  or  body  of  the  child ;  the  winding  of  the  cord  so  tightly 
around  the  neck  or  some  other  part,  as  to  obstruct  simultaneously  the  venous 
circulation  in  the  brain,  and  that  of  the  blood  in  the  umbilical  vessels;  the 
premature  separation  of  the  placenta,  whether  it  be  inserted  upon  the  neck 
or  not,  for  since  the  separation  necessarily  produces  the  rupture  of  the  utero- 
placental vessels,  it  renders  the  fetal  hsematosis  as  impossible  as  does  the 
compression  of  the  cord:  the  great  retraction  of  the  uterus,  when  in  delivery 


ATTENTIONS    TO   THE    WOMAN    AND    CHILD.  413 

by  the  breech  the  head  only  remains  in  the  excavation,  and  the  child  is 
unable  to  respire ;  for  this  retraction  renders  the  vessels  of  the  uterus  almost 
impermeable  to  blood.  In  all  these  cases,  the  asphyxia  results  evidently 
from  a  suspension  of  the  placental  respiration,  and  it  is  the  contact  of 
black  blood  with,  the  brain,  which  paralyzes  its  action  in  the  fetus  as  well 
as  in  the  adult. 

Finally,  it  is  plain  that  after  the  child  is  born,  the  accumulation  of  mucus 
in  the  nose,  mouth,  and  air-passages,  may  also  produce  asphyxia  by  prevent- 
ing the  introduction  of  air  into  the  bronchia? ;  here,  however,  the  mode  of 
operation  is  precisely  the  same  as  in  the  adult,  since  it  results  from  a  me- 
chanical obstacle  to  the  introduction  of  the  external  air  into  the  pulmonary 
vesicles. 

In  consequence  of  the  action  of  some  one  of  these  causes,  the  foetus  may  be 
born  in  a  state  of  apparent  death,  and  exhibit  the  very  different  symptoms 
which  we  have  already  mentioned  ;  thus,  in  most  cases,  the  surface  of  the 
body  has  a  swollen  appearance,  and  is  of  a  violet,  or  rather  of  a  blackish- 
blue  color,  the  discoloration  being  more  marked  at  the  upper  parts  of  the 
trunk,  and  more  particularly  on  the  face  than  elsewhere.  The  muscles  are 
motionless ;  the  limbs  preserve  their  flexibility,  and  the  body  its  heat  ;  the 
pulsations  of  the  cord,  of  the  radial  artery,  and  even  those  of  the  heart,  are 
obscure  or  insensible. 

Where  a  post-mortem  examination  is  made,  the  vessels  of  the  encephalon 
are  found  engorged  with  blood ;  at  times,  this  fluid  is  even  effused  on  the 
surface  of  the  membranes,  or  into  the  substance  of  the  brain  itself,  though 
most  generally,  says  M.  Cruveilhier,  the  effusion  is  limited  to  the  surface  of 
the  cerebellum  ;  sometimes  it  covers  the  posterior  lobes  of  the  cerebrum,  but 
it  is  rarely  found  in  the  ventricles  of  the  brain ;  and,  in  all  the  cases  examined 
by  him,  there  was  blood  enough  in  the  cavity  of  the  vertebral  arachnoid 
membrane  to  distend  the  dura  mater.  Again,  those  congestions  of  the  liver 
that  are  so  common  in  infants,  are  then  particularly  apt  to  be  met  with  ; 
but,  says  Billard,  they  vary  considerably  as  regards  the  quantity  of  blood 
accumulated  in  the  tissues  of  the  organ  ;  for,  in  some  instances,  it  is  found 
there  in  such  great  abundance  as  to  give  rise  to  a  sanguineous  exudation  on 
the  exterior  of  the  organ,  the  convex  surface  of  which  is  discolored  and 
moistened  by  a  layer  of  effused  blood,  and  I  have  even  known  an  extrava- 
sation of  tins  fluid  into  the  abdomen  to  result  from  this  turgescence.  The 
lungs  are  also  gorged  with  blood. 

The  external  condition  of  the  asphyxiated  foetus  is  not  always  such  as  we 
have  just  described,  for,  as  M.  Jacquemier  has  observed,  nothing  is  more 
common  than  to  find  the  fetus  born  without  any  anomalous  coloration  of 
the  skin,  and  even  with  a  remarkable  degree  of  pallor  and  flaccidity  of  the 
limbs ;  and  this,  notwithstanding  the  apparent  death  has  been  produced  by 
compression  of  the  cord.  Can  this  difference  be  due,  as  M.  Jacquemier 
supposes  in  the  latter  case,  to  a  sudden  suspension  of  the  placental  respira- 
tion, whilst  in  the  former  the  cessation  was  slow  and  gradual  ?  This  expla- 
nation is  probable,  inasmuch  as  the  same  diilerenees  are  observed  in  the 
asphyxia  of  adults,  and  as,  according  to  M.  Devergie,  those  persons  who 
are  killed  by  the  falling  in  upon  them  of  earth,  present  the  same  discoloia- 


414  LABOR. 

tion  of  tlie  integuments.  The  suddenness  of  the  real  death  may  explain  the 
peculiarity  under  these  circumstances ;  but  it  must  Dot  be  forgotten  that  this 
external  pallor  is  also  the  consequence  of  a  slow  but  prolonged  asphyxia,  and 

that  it  often  succeeds  to  the  violet  hue  of  the  tissues;  that  we  everyday 
witness  this  succession  going  on  before  our  eyes  when  the  asphyxia  has  lasted 
too  Ion--,  and  that  a  child  horn  with  a  very  deep  color,  becomes  rapidly  pale 
and  flaccid,  if  the  means  employed  fail  to  excite  respiration. 

In  the  latter  case,  the  discoloration  of  the  tissues  is  the  symptomatic  ex- 
pression of  a  more  advanced  stage:  the  pulsations  of  the  heart,  which  before 
were  sufficiently  strong  and  rapid,  become  less  frequent  and  feebler,  return 
only  at  long  intervals,  and  real  death  soon  succeeds  to  the  apparent  one. 
Now  these  phenomena,  which  we  observe  occasionally,  take  place  in  the 
same  manner  whilst  the  foetus  is  still  contained  in  the  womb,  but  is  deprived 
of  the  placental  respiration. 

When,  at  the  moment  of  birth,  the  asphyxia  has  lasted  but  a  short  time, 
the  child  will  exhibit  turgescence  of  the  face,  the  violet  hue  of  the  skin,  firm- 
ness of  flesh,  and  frequent  and  regular  pulsations  of  the  heart;  if  a  longer 
period  has  elapsed  since  the  interruption  of  the  fosto-maternal  circulation,  the 
child  will  he  pale  and  discolored,  and  the  pulsations  of  the  heart  and  cord 
feeble  and  intermitting;  finally,  if  the  asphyxia  has  lasted  longer  than  is 
compatible  with  the  life  of  the  heart,  the  child  will  be  really  dead  at  the 
time  of  its  expulsion. 

These  two  conditions,  which  are  apparently  so  different,  are  due  to  the 
same  cause,  and  are  simply  two  decrees  of  asphyxia.  Though  in  an  etio- 
logical sense,  no  distinction  can  be  made  between  them,  they  are  important 
as  regards  the  prognosis,  for  one  is  much  more  serious  than  the  other,  and, 
as  regards  treatment,  the  same  means  are  not  applicable  to  both. 

M.  Pajot  informs  me  that  he  has  found  these  observations  to  hold  true  as 
regards  the  adult. 

2.  Lesions  of  the  Fecial  Circulation.  —  Ruptures  of  the  cord  or  of  the  pla- 
centa may,  of  themselves,  give  rise  to  such  a  degree  of  hemorrhage  as  to  en- 
i  langer  the  life  of  the  foetus ;  fortunately,  however,  they  are  quite  rare.  When 
the  hemorrh;iire  is  profuse,  the  child  dies  before  the  labor  is  over;  but  should 
anything  happen  to  arrest  the  discharge  of  blood,  the  child  may  be  born 
alive,  but  in  a  state  of  apparent  death  resembling  syncope.  The  deficiency 
of  nervous  influence  is  here  manifestly  due  to  the  fact  that  the  medulla 
oblongata  and  the  brain  no  longer  receive  a  sufficient  amount  of  blood  to 
enable  them  to  react  upon  the  nerves  of  inspiration.  The  condition  is  a 
most  dangerous  one.  The  child  is  pallid,  and  its  muscles  are  completely 
relaxed;  sometimes,  however,  it  makes  a  few  short  inspirations,  and  utters 
some  very  feeble  cries;  but  if  the  hemorrhage  has  been  at  all  profuse,  it 
succumbs  in  a  very  short  time. 

3.  Lesions  of  the  Nervous  Centres. — The  cerebro-spinal  system  presides 
over  none  of  those  functions  whose  integrity  is  necessary  to  the  maintenance 
id'  foetal  life;  the  respiration,  circulation,  and  nutrition  being  subject  ex- 
■lusivelv  to  the  nerves  of  organic  life.     These  ganglions  and  their  nerves 

derive  from  the  arterial   blood  that  principle  of  organic  sensibility  and 
motility  which  is  uecessary  to  the  production  of  involuntary  or  automatic 


ATTENTIONS   TO  THE   WOMAN   AND   CHILD.  415 

movements,  as  also  to  the  maintenance  of  the  irritability  and  vitality  of  the 
organs.  Although  the  foetus  possesses  organs  of  animal  life,  its  vitality 
is  purely  vegetative  or  organic.  This  fact  serves  to  explain  the  life  and 
development  of  acephalse,  for  where  the  organs  are  absent,  the  functions 
are  also  wanting;  yet  these  monsters  are  endowed  with  irritability,  are 
capable  of  motion,  and  their  life  is  preserved  intact,  until  the  termination  of 
pregnancy. 

Since  the  brain  and  spinal  marrow  have  nothing  to  do  with  the  perform- 
ance of  the  fatal  functions,  we  readily  foresee  that  any  lesions  which  may 
affect  them  during  pregnancy  or  labor,  cannot  disturb  the  harmony  of  those 
functions,  or  have  any  influence  whatever  upon  the  intra-uterine  vitality. 
Therefore  it  is  only  after  birth  that  the  cerebro-spinal  alteration  or  paralysis 
prevents  the  establishment  of  animal  life,  even  though  the  organic  life  is 
still  manifested  by  the  integrity  of  the  circulation,  and  even  of  the  placental 
respiration.  The  first  respiratory  act  is,  as  we  have  said  before,  the  conse- 
quence of  an  excitement  of  the  medulla  oblongata,  produced  by  the  impres- 
sion of  the  temperature  of  the  surrounding  air  upon  the  skin  of  the  new-born 
child.  For  this  impression  to  be  effectual,  however,  it  is  necessary  that  the 
sensation  should  be  perceived  by  the  central  organ,  which  is  rendered  in- 
capable of  perceiving  it  by  serious  lesions  of  the  cerebro-spinal  axis.  This 
important  distinction  should  therefore  be  made  between  the  various  circum- 
stances capable  of  reducing  the  foetus  to  the  state  of  apparent  death,  namely, 
that  the  foetus  may  be  destroyed  in  the  womb  by  asphyxia  and  hemorrhage, 
whilst  lesions  of  the  nervous  centres  always  cause  it  to  be  born  in  a  state  of 
apparent  death. 

We  should  also  interpret  in  this  way  the  effect  which  may  be  produced  by 
the  violent  compression  which  the  brain  undergoes  in  certain  cases  of  con- 
tracted pelvis;  that  which  may  result  from  the  application  of  the  forceps  or 
lever  under  circumstances  of  difficulty;  that  which  results  from  vascular 
congestion  due  to  an  obstruction  to  the  return  of  venous  blood  in  certain 
deliveries  by  the  face;  in  cases  where  the  cord  is  wound  tightly  several  times 
round  the  neck,  as  also  where  it  is  strongly  grasped  by  a  spasmodic  con- 
traction of  the  neck  of  the  uterus;  and  finally,  to  the  compression  sometimes 
produced  by  effusions  of  blood,  either  upon  the  surface,  or  into  the  substance 
of  the  orain  itself. 

So,  also,  is  to  be  explained  the  mode  of  action  of  lesions  of  the  medulla 
oblongata,  such  lesions  as  we  know  are  easily  produced  by  extreme  rotation 
of  the  head,  by  tractions  upon  the  head,  or  the  pelvis  when  the  head  is 
arrested  in  an  elevated  position,  and  finally,  by  effusions  at  the  base  of  the 
brain  and  upper  part  of  the  vertebral  canal. 

As  lesions  of  the  brain  are  not  absolutely  incompatible  with  the  establish- 
ment of  respiration,  they  are  not  so  dangerous  as  those  of  the  medulla  oblon- 
gata. The  destr  iction  of  a  large  portion  of  the  encephalon  bus  not  always 
prevented  the  child  from  breathing  and  crying  after  its  birth,  and  even  from 
living  for  several  days.  A  similar  fact  is  presented  by  anencephalous  foetuses. 
By  this  we  are  advised  that,  in  difficult  labors,  the  temporary  compression 
of  the  head  may  also  suspend  momentarily  the  action  of  the  brain,  but  that 
as  this  suspension  does  not  absolutely  preclude  respiration,  the  Bpecies  of 


416  LABOR. 

shock  or  concussion  which  the  brain  experiences  may  pass  away  so  soon  a 
not  to  interfere  with  the  continuance  of  life. 

It  is  different,  however,  with  lesions  of  the  medulla  oblongata,  which  is 
the  only  motor  of  the  respiratory  movements:  it  cannot  be  seriously  affected 
without  rendering  extra-uterine  life  impossible.  This  explains  the  frequent 
death  of  children  in  pelvic  presentations,  when  tractions  have  been  made 
upon  the  trunk  with  Lie  object  of  disengaging  the  head. 

Treatment.  —  Since  apparent  death,  however  produced,  may  present  the 
very  different  symptoms  already  mentioned,  it  is  evident  that  mere  inspec- 
tion of  the  child  can  afford  no  information  as  to  the  cause  of  its  condition. 
Although  we  regard  the  discoloration  of  the  skin  and  relaxation  of  the  ex- 
tremities as  signs  of  very  grave  import,  it  is  impossible  to  determine  the 
extent  of  the  cerebral  disorders,  and  consequently  to  foresee  the  result  of 
measures  calculated  to  restore  the  child.  In  this  state  of  uncertainty,  all 
cases  should  be  treated  as  though  they  afforded  a  chance  of  success.  The 
lapse  of  half  an  hour,  an  hour,  or  even  more,  from  the  time  of  delivery,  is  not 
sufficient  cause  for  despair,  since  a  number  of  facts  may  be  mentioned  going 
to  prove  that  children  have  been  in  an  asphyxiated  condition  for  an  hour, 
and  were  afterwards  restored  to  life.  Long  continued  silence  of  the  heart,  the 
entire  absence  of  pulsations  at  the  precordial  region,  frequently  determined 
at  intervals,  is  the  only  sign  which  can  be  regarded  as  destructive  of  all  hope. 
The  heart  is  the  ultimum  moriens,  and  I  do  not  believe  that  efforts  to  restore 
its  pulsations,  when  once  completely  extinguished,  have  ever  been  crowned 
with  success.  But  the  softness  and  flaccidity  of  the  tissues,  and  coldness  of 
the  body  and  face,1  are  no  reason  for  abandoning  the  child,  j>rovided  the 
heart  still  beats,  however  feebly,  slowly,  or  irregularly. 

When  the  child  is  born  with  a  general  injection  of  the  capillaries  of  the 
face  and  trunk,  when,  in  short,  it  presents  the  characters  of  the  state  formerly 
termed  apopleasy,  it  is  evident  that  the  first  indication  is  to  relieve  the  engorge- 
ment of  the  head  and  lungs,  which  is  done  by  promptly  cutting  the  um- 
bilical cord,  and  allowing  a  few  spoonfuls  of  blood  to  escape,  when  the 
respiration  is  most  usually  established  soon  after,  if  there  are  no  mechanical 
obstacles,  such  as  mucus  in  the  fauces,  to  the  introduction  of  air  into  the 
lungs ;  and  where  these  do  exist,  they  may  be  removed  by  the  extremity 
of  the  little  finger,  or  with  the  feathered  end  of  a  quill ;  the  blue  and  violet 
color  of  the  surface  will  then  be  found  to  gradually  disappear,  and  give  place 
to  a  rosy  hue,  at  first  on  the  lips,  then  on  the  cheeks,  and  afterwards  over 
the  rest  of  the  body.  However,  in  practice,  we  sometimes  find  the  circula- 
tion so  enfeebled  or  benumbed,  as  it  were,  that  the  blood  will  not  run  from 
the  umbilical  arteries;  its  effusion  may  then  be  encouraged  by  plunging  the 
child  into  a  warm  bath,  or  by  squeezing  the  cord  several  times  from  ics 
insertion  towards  the  cut  extremity  ;  and  where  this  does  not  prove  success- 
ful in  obtaining  blood,  some  advise  the  application  of  a  leech  behind  each 
ear.  But  as  this  application  would  occasion  the  loss  of  precious  time,  it  is 
better  to  have  recourse  at  once  to  other  measures. 

1  The  experiments  of  M.  Brown-S6qnard  on  warm-blooded  animals,  prove  that  the 
time  for  which  they  are  capable  of  resisting  asphyxia  is  greater  in  proportion  as  they 
are  subjected  to  a  lower  temperature. 


.     ATTENTIONS    TO   THE    WOMAN    AND    CHILD.  417 

The  small  bleeding  being  practised  or  not,  every  effort  should  be  made, 
by  the  use  of  various  stimulants,  to  excite  the  sensibility  of  the  skiu,  and 
the  rellex  action  of  the  cutaneous  nerves. 

According  to  Marshall  Hall,  the  best  plan  is  to  sprinkle  the  face  and  body 
of  the  child  vigorously  with  cold  water;  immediately  after  which,  it  should 
be  immersed  in  a  warm  bath,  and  then  wrapped  in  warm  flannels.  The 
efficiency  of  this  plan  of  treatment,  which  may  be  repeated  several  times, 
depends  especially  upon  the  rapidity  with  which  it  is  executed.  The  im- 
pression of  both  the  cold  and  heat  should  be  sudden.  Afterwards,  the  skin 
may  be  stimulated  by  frictions  with  the  hand,  or  a  brush,  by  dry  flannel,  or 
with  any  irritating  liquors,  such  as  vinegar  or  brandy;  M.  Moreau  strongly 
recommends,  and  with  reason,  slight  blows  to  be  made  with  the  palmar  sur- 
face of  the  fingers  upon  the  shoulders  and  thighs.  In  grave  cases,  I  prefer 
flagellating  the  thorax  and  loins  vigorously  with  a  piece  of  wet  linen.  It,  is 
also  often  very  useful  to  irritate  the  mucous  surfaces.  A  little  brandy  or 
vinegar  may  be  placed  in  the  mouth,  or  the  fumes  of  burnt  paper  blown 
into  the  anus.  A  feather  may  be  dipped  into  vinegar  and  then  introduced 
into  the  nose  or  fauces  ;  this  may  be  used  at  the  same  time  to  clear  away  the 
mucous  secretions  of  the  latter,  which  prevent  the  inhalation  of  air ;  and 
where  there  is  reason  to  suppose  that  such  secretions  have  accumulated  to  a 
considerable  extent  in  the  air-passages,  the  advice  of  Dewrees  should  be  fol- 
lowed, by  placing  the  child  on  its  belly,  taking  care  to  elevate  the  feet  higher 
than  the  head,  and  at  the  same  time  gently  shaking  it,  so  as  to  clear  out  the 
trachea,  and  thus  facilitate  the  introduction  of  air  ;  "  for,"  says  the  American 
author,  "  this  is  a  measure  of  great  utility,  by  which  I  am  every  way  per- 
suaded that  I  have  preserved  the  lives  of  many  children."  After  a  few 
moments,  the  child  should  be  again  plunged  into  a  warm  bath,  rubbed  with 
warm  flannels,  and  then  immediately  subjected  to  cold  aspersions. 

All  these  measures  should  be  continued  for  a  long  time  after  respira- 
tion has  been  restored  and  become  regular,  in  order  to  prevent  secondary 
asphyxia. 

The  child's  body  may  be  exposed  with  advantage  to  a  current  of  cold  air, 
giving  it  at  the  same  time  a  swinging  motion,  and  even  after  it  has  been 
restored  and  dressed,  its  face  may  be  exposed  to  the  fresh  air,  or,  what  is 
better,  fanned,  for  a  short  time. 

It  has  been  advised  to  make  use  of  strong  suction  on  the  breasts,  for  the 
purpose  of  dilating  the  thorax  mechanically,  "  which,"  says  Desormeaux, 
"although  without  effect  for  the  proposed  object,  appears  to  me  admirably 
calculated  to  stimulate  the  muscles  that  move  the  ribs."  But  a  more  power- 
ful remedy,  highly  extolled  by  the  same  author,  is  a  sort  of  douche  made  by 
the  mouth  directly  on  the  parietes  of  the  thorax  ;  this  douche  is  performed 
by  taking  a  mouthful  of  brandy  and  blowing  it  forcibly  against  the  breast; 
and  it  is  rarely  necessary,  he  remarks,  to  repeat  it  many  times,  for  it  is 
found  to  produce  a  convulsive  contraction  of  the  inspiratory  muscles  almost 
immediately ;  the  blood  and  air  penetrate  the  lungs,  and  the  respiration  is 
irregularly  established,  being  at  first  feeble  and  spasmodic,  but  soon  becom- 
ing stronger  and  more  regular.  I  have  often  used  successfully  with  tin 
27 


418  LABOR. 

same  object,  a  cold  douche,  produced  by  pouring.  :i  stream  of  cold  water 
upon  the  precordial  region,  from  an  elevation  of  about  a  yard. 

If  the  excitation  of  the  spinal  and  facial  nerves  is  insufficient,  the  branches 
of  the  pneumogastric  uerve  should  be  acted  on  by  insufflation. 

This  measure  can  now  boast  of  such  a  degree  of  success,  as  to  make  it 
proper  to  have  recourse  to  it  whenever  the  means  just  mentioned  have  failed. 
M.  Depaul  has,  in  an  excellent  memoir  upon  the  subject,  completely  refuted 
the  objections  urged  against  it,  and  confirmed  by  his  experiments  the  pre- 
vious results  of  Dumeril  and  Magendie.  Like  them,  he  found  that  a  false 
idea  has  been  entertained  of  the  powers  of  resistance  of  the  pulmonary 
vesicles,  and  that  it  is  necessary  to  blow  much  more  strongly  than  is  required 
to  produce  a  simple  dilatation,  in  order  to  effect  their  rupture.  He  has 
proved  by  instances,  that  children  have  been  restored  to  life,  whom  the 
failure  of  the  mean-  commonly  advised  seemed  to  devote  to  certain  death  ; 
also,  that  in  eases  where  it  was  unsuccessful,  because  the  lesions  occasioning 
the  apparent  death  were  beyond  the  resources  of  art,  it  had  the  effect,  when 
the  pulsations  of  the  heart  had  not  ceased  entirely,  to  render  them  stronger 
and  more  frequent,  and  sometimes  even  to  determine  a  spontaneous  though 
imperfect  inspiration. 

I  would  add,  that  long  continued  insufflation  seemed  to  me,  in  three  cases, 
to  be  more  effectual  than  is  claimed  in  the  above  paragraph,  for  not  only  did 
it  excite  spontaneous  inspirations,  but  the  respiration  became  gradually  regu- 
lar, and  existence  was  prolonged  for  ten,  twelve,  and  in  one  case  for  twenty- 
two  hoitis,  in  spite  of  mortal  lesions  of  the  brain.  Now  it  will  readily  be 
understood  that,  in  very  many  cases,  the  family  might  attach  great  impor- 
tance to  twenty-four  hours  of  life  in  a  new-born  child. 

M.  Depaul,  who  has  rendered  a  rial  service  in  calling  attention  to  a  mea- 
sure generally  abandoned  by  some  as  dangerous,  and  by  others  as  useless, 
also  proposes  some  rules  of  conduct,  which  I  think  it  right  to  mention  briefly. 

He  uses  Chaussier's  canula,  dispensing,  however,  with  the  lateral  openings, 
and  substituting  for  them  a  terminal  one. 

'fin  child,  whose  temperature  is  to  be  maintained  by  warm  coverings, 
should  be  placed  with  the  breast  higher  than  the  pelvis,  and  the  head  thrown 
a  little  back,  so  as  to  render  the  front  of  the  neck  rather  more  projecting. 
Saving  cleansed  the  tongue  and  pharynx  from  mucus,  the  forefinger  of  the 
left  band  should  be  conducted  along  the  median  line  of  the  tongue  to  the 
epiglottis.  The  right  hand  holds  the  tube  like  a  pen,  and  directs  its  small 
extremity  along  the  linger  to  the  opening  of  the  larynx,  inclines  it  towards 
the  left  commissure  of  the  lips,  and  by  gentle  movements  endeavors  to  raise 
the  epiglottis;  it  is  then  only  necessary  to  elevate  the  instrument,  carrying  it 
at  the  same  time  toward  the  median  line,  when  its  extremity  will  pass 
through  the  glottis.  This  is  the  only  part  of  the  operation  which  presents 
any  difficulty,  for  it  is  not  uncommon  for  the  tube  to  enter  the  oesophagus. 
Before  r<  sorting  to  insufllation,  we  should  make  sure  of  its  situation  bypass- 
in.:'  the  tinger  upon  the  larynx  and  trachea,  and  observing  whether  the 
larynx  follows  the  instrument  when  the  latter  is  moved  from  side  to  side- 
However,  the  first  insufllation  nveals  the  error  immediately,  for  when  the 
instrument  has  passed  into  the  oesophagus,  a  considerable  elevation  of  the 


ATTENTIONS   TO   THE    WOMAN   AND   CHILD.  419 

epigastrium  precedes  that  of  the  base  of  the  chest ;  if,  on  the  contrary,  it  is 
in  the  larynx,  the  chest  is  dilated  uniformly,  and  the  epigastric  projection  is 
produced  exclusively  by  the  depression  of  the  diaphragm. 

To  prevent  the  reflux  of  the  air,  and  to  oblige  it  to  enter  the  air-passages, 
every  point  of  exit  by  the  oesophagus,  mouth,  and  nostrils  should  be  closed. 
The  anterior  wall  of  the  oesophagus  is  applied  against  the  posterior,  by  a 
moderate  pressure  with  the  instrument.  The  lips  are  pressed  closely  to  the 
sides  of  the  canula  by  means  of  the  thumb  and  forefinger,  whilst  the  nostrils 
are  stopped  by  pinching  the  nose  between  the  two  middle  fingers. 

The  insufflations  should  be  quite  near  to  each  other.  M.  Depaul  thinks 
that  from  ten  to  twelve  should  be  made  in  a  minute.  The  greater  part  of 
the  air  is  expelled  after  each  by  the  elasticity  of  the  pulmonary  vesicles ; 
it  may  be  useful,  however,  especially  at  the  commencement,  to  render  the 
expiration  more  complete,  by  pressure  properly  applied  with  the  whole  hand 
on  the  front  of  the  chest. 

The  length  of  time  for  which  it  is  necessary  to  continue  the  insufflations 
varies  much.  Thus,  there  are  facts  showing  that  sometimes  a  quarter  of  an 
hour  has  been  sufficient,  whilst  at  others,  it  was  necessary  to  continue  them 
for  three-quarters  of  an  hour,  an  hour,  or  even  an  hour  and  a  half. 

When,  under  their  influence,  the  action  of  the  heart  has  been  so  far  restored 
as  to  be  at  from  a  hundred  to  a  hundred  and  thirty  times  a  minute,  I 
think,  says  M.  Depaul,  that  the  physician  should  continue  until  spontaneous 
inspirations  appear,  and  are  repeated  at  the  rate  of  at  least  five  or  six  per 
minute ;  since  to  stop  after  the  first  one,  would  in  many  cases  endanger  the 
life  of  the  child.  When,  however,  after  having  awakened  the  pulsations  of 
the  heart,  and  even  obtained  some  efforts  at  inspiration,  all  become  more 
feeble  and  disappear,  the  insufflation  may  be  dispensed  with  after  the  lapse 
of  from  ten  to  twelve  minutes,  for,  under  these  circumstances,  I  have  never 
known  a  child  to  be  saved. 

It  is  necessary  to  withdraw  the  canula  from  time  to  time,  in  order  to  clear 
it  of  mucus.  When  the  trachea  contains  much  mucus,  which  is  manifested 
by  gurgling,  it  may  be  drawn  into  the  tube  by  suction,  and  the  future  in- 
sufflations be  thus  rendered  more  useful. 

When  spontaneous  inspirations  occur,  the  insufflations  may  be  suspended 
for  the  moment. 

Finally,  all  these  means  having  failed,  should  a  galvanic  battery  be  at 
hand,  currents  of  electricity  might  be  passed  through  the  muscles  of  inspira- 
tion; it  is,  however,  an  auxiliary  upon  which  but  little  reliance  can  be  placed. 

Electricity  has,  in  fact,  much  less  action  upon  the  foetus  than  upon  the 
adult.  It  has,  for  example,  been  proved  by  experiment,  that  well-developed 
foetal  serpents  were  but  slightly  sensitive  to  the  action  of  galvanism  before 
having  breathed,  whilst  shortly  afterward  they  were  endowed  with  a  very 
delicate  sensibility. 

The  same  measures  should  be  used  in  cases  of  apparent  death,  in  which 
the  children  are  pale  and  colorless:  here,  however,  far  from  allowing  the 
umbilical  cord  to  bleed,  it  should  be  tied  instantly,  even  before  dividing  it. 

Some  persons  have  recommended  that  the  umbilical  cord  be  not  cut  in 
cases  of  asphyxia,  until  after  the  pulmonary  respiration  has  been  fully 


420  LABOR. 

established,  hoping  that  the  continuance  of  the  foeto-placental  ci  culatim 
might  replace  the  extra-uterine  one  that  is  wanting.  Without  admitting,  with 
Dr.  King,  that  this  practice,  by  allowing  the  contractions  of  the  heart  to 
drive  all  the  blood  into  the  placenta,  would  expose  tin:  fetus  to  death  from 
1"--  ,>f  the  circulating  fluid,  I  think  that  in  the  majority  of  cases  the  pre- 
caution Is,  to  say  the  least,  useless,  and  even  hurtful,  by  occasioning  the  loss 
of  precious  time.  In  fact,  the  placenta  is  almost  always  partly,  or  even 
entirely  detached,  shortly  after  the  child  is  expelled;  and  even  were  this  not 
the  case,  the  retraction  of  the  uterus  following  its  expulsion,  has  so  modified 
the  circulation  in  the  walls  of  the  uterus  and  that  of  the  utero-placental 
vessels,  that  the  newly-born  infant  would  certainly  find  its  resources  in  thai 
direction  exhausted. 

However,  if  the  touch  does  not  discover  the  placenta  situated  upon  the 
neck,  and,  consequently,  there  is  reason  to  suppose  that  it  retains  its  normal 
relations  with  the  womb,  we  may,  when  the  fetus  is  pale  and  discolored, 
defer  cutting  the  cord,  especially  should  it  still  exhibit  pulsations.1  As  soon, 
however,  as  the  pulsations  have  ceased,  or  it  is  ascertained  that  the  placenta 
is  detached,  its  section  should  be  practised  immediately. 

Some  children,  after  having  cried  and  breathed  quite  freely,  fall,  after  the 
Lapse  of  several  hours,  and  sometimes  even  days,  into  a  state  of  apparent 
death,  which  soon  terminates  in  real  death  unless  assistance  is  promptly 
rendered.  Therefore  it  is  prudent  to  be  carefully  on  the  watch  for  the  first 
few  days.  This  secondary  apparent  death  may  be  due,  like  that  just 
described,  to  a  true  asphyxia,  or  to  a  deficiency  of  nervous  influence,  foi 
which  the  stimulants  employed  immediately  after  birth  have  proved  but  a 
momentary  remedy.  Asphyxia  may  be  produced  either  by  a  foreign  body 
[•laced  over  the  mouth  and  nostrils,  or  by  an  accumulation  of  mucus  in  the 
-.  To  remove  the  foreign  bodies,  and  clear  out  the  fauces  with  the  aid 
of  a  feather,  and  the  bronchia  by  exciting  vomiting  by  tickling  the  palate, 
are  the  first  measures  to  be  used.  If  the  face  is  of  a  violet  color,  a  leech 
may  be  placed  with  advantage  behind  each  ear,  or,  as  recommended  by 
Kennedy,  upon  the  fontanelles.  When  the  accidents  are  attributable  to 
deficient  cerebral  action,  the  excitants  already  mentioned  must  again  be  had 
recourse  to. 

Excessive  debility  of  the  child,  due  to  some  one  of  the  circumstances 
already  pointed  out,  should  be  combated  by  the  same  means  used  for 
apparent  death.  In  those  cases  where  the  infant  is  only  very  feeble,  because 
it  i<  horn  before  term,  or  in  consequence  of  a  prolonged  sickness  on  the  part 
of  the  mother,  very  great  care  is  requisite  to  maintain  a  high  degree  of  tem- 
perature  by  surrounding  it  with  cotton  wadding  and  bottles  containing  hot 
water,  since  heat  is  then  the  best  stimulant. 

For  the  first  few  days,  and  sometimes  even  weeks,  its  alimentation  demands 
some  precaution.      It  is  very  important  that  a  nurse  should  be  procured  at 
once,  whose  milk  Hows  so  easily  that  she  can  herself  project  a  few  spoonfuls 
into  'he  mouth  of  the  child;  for  it.-  feebleness  often  renders  the  necessary 
1  Froi  ota  made  by  Budin,  the  amount  of  blood  escaping  from  the  placental  end  when 

:  was  tied  immediately  after  ihebiith  of  the  child  was  found  to  be  about  thn  eoi 
than  when  a  delay  of  several  minutes  was  allowed,  which  shows  a  loss  of  that  much  blood  v.  hicn 
would  otherwise  pass  into  it-  circulation.    It  has  also  been  'hown  by  Hofmeier  and  others  that 
there  i-  less  loss  in  weight  ill  the  new-burn  infant  when  the  cord  is  nut  tied  until  the  pulsations 
have  entirely  ceased. 


PHENOMENA    APPERTAINING    TO   THE    LYING-IN    STATE.         421 

effort  at  suction  impossible.     It  is  equally  important  to  give  it  only  the  first 
milk,  which  is  easier  digested. 

Umbilical  hemorrhage  of  spontaneous  origin  has  been  noticed  by  some 
authors.  Dr.  J.  S.  Gibb  has  recently  written  a  monograph  upon  it  (Philor 
delphia  Med.  Times,  May,  1884),  in  which  the  great  fatality  is  shown,  and 
the  difficulty  of  treating  it  locally  is  considered.  The  hemorrhage  may 
occur  at  any  time.  The  blood  is  usually  non-coagulable.  The  causes  are 
involved  in  obscurity.  It  is  usually  associated  with  jaundice  and  the  hem- 
orrhagic diathesis.  

CHAPTER   IX. 

OF   THE    PHENOMENA    APPERTAINING    TO   THE    LYING-IN    STATE. 

This  term  Tor  that  of  the  puerperal  condition)  is  applied  to  the  period 
immediately  following  the  delivery,  during  which  the  uterus  and  genital 
organs,  and  indeed  the  whole  economy,  gradually  return  to  their  ordinary 
condition.1 

The  attendant  phenomena  may  be  divided  into  the  natural,  and  the  un- 
natural or  morbid,  including  under  the  latter  head  all  the  diseases  to  which 
the  lying-in  woman  is  exposed  ;  but  the  former  only  claim  our  attention  here. 

A  feeling  of  depression,  or  lassitude,  such  as  that  experienced  after  an 
unusual  or  an  immoderate  exercise,  succeeds  the  agitation  caused  by  the 
labor ;  and  it  not  unfrequently  happens  that  the  patient  has  scarcely  reached 
her  bed,  when  she  is  attacked  by  a  chill,  severe  enough  at  times  to  produce 
x  chattering  of  the  teeth  ;  but  this  soon  passes  off,  the  pulse  increases  in 
strength,  the  heat  of  the  surface  returns,  the  skin  becomes  humid,  a  salutary 
moisture  appears,  and  the  various  functions  are  re-established,  while  the  most 
perfect  calm  and  the  most  delightful  slumber  replace  the  past  disorder. 
Now,  although  this  slumber  of  the  patient  is  to  be  respected,  nevertheless  it 
is  desirable  that  it  should  not  take  place  until  a  few  hours  after  the  delivery, 
unless  the  physician  should  be  at  hand  to  watch  attentively  over  the  state 
of  the  circulation,  and  the  condition  of  the  womb  during  this  recuperative 
repose,  because  some  women  have  been  attacked  when  in  this  state  with 
internal  discharges,  and  have  awakened  exhausted  by  the  loss  of  blood. 
Therefore,  although  on  account  of  the  rarity  of  this  accident  the  patient 
shouid  not  be  prevented  from  sleeping,  it  is  necessary  to  watch  over  her 
during  her  slumber,  or  at  least  to  have  her  carefully  observed  by  an  intelli- 
gent nurse. 

After  the  first  nap  is  over,  she  might  sit  up  in  bed  a  few  moments  to  take 
a  little  broth,  as  this  position  refreshes  her,  and  also  facilitates  the  escape  of 
the  lochia  that  had  accumulated  in  the  vagina.  The  patient  is  the  more 
enfeebled  as  the  loss  of  blood  has  been  greater,  or  the  duration  of  the  labor 
prolonged. 

The  nervous  susceptibility  is  also  highly  exalted,  and  the  skin,  whose 
activity  was  diminished  during  gestation,  now  regains  a  more  exalted  vitality  ; 
it  is  soft,  humid,  and  is  always  covered  with  a  dewy  perspiration  during  the 
first  week.  This  sweat,  is  sometimes  very  abundant,  particularly  when  she 
is  too  warmly  covered,  and  it  is  not  at  all  unusual  to  find  it  followed  by  a 
miliary  eruption  and  a  distressing  pricking  sensation.  Such  eruptions  were 
1  The  process  by  which  tlic.  uterus  returns  to  its  ordin  ry  non-puerperal  condition  i>  known  as 
Involution. 


422  LABOR. 

exceedingly  frequent  in  former  times,  when  it  was  thought  useful  to  push  the 
skin,  as  it  was  called,  and  to  make  the  woman  perspire  by  surrounding  her 
with  thick  coverlets;  now,  on  the  contrary,  they  are  quite  rare,  and  where 
they  do  show  themselves,  are  easily  made  to  disappear  by  taking  the  neces- 
sary precautions  to  diminish  the  cutaneous  secretion. 

[After  delivery  the  pulse  becomes  Bofter,  fuller,  and  sunn  slower.  We  propose, 
however  going  somewhat  into  detail  in  reference  t<>  this  subject,  for  the  examina- 
tion of  the  pulse  in  newly-delivered  females  is  of  such  capital  importance  that  by 
simply  paying  attention  to  the  information  which  it  affords,  we  are  enabled  to 
diagnosticate  almost  certainly  a  state  of  health  or  of  disease.  The  study  of  the 
pulse,  th<  refore,  yields  extremely  valuable  information  to  the  accoucheur,  but  we  can- 
not in  this  place  treat  of  the  indications  which  it  supplies  in  puerperal  diseases,  and 
shall  confine  our  attention  to  the  changes  which  it  undergoes  in  a  healthy  woman  after 
delivery. 

We  would  state  in  the  first  place,  that  the  mean  rate  of  the  pulse  in  adult  women 
is  about  seventy-five  per  minute,  and  becomes  somewhat  more  frequent  during 
pregnancy  (see  page  157)  and  especially  during  labor  (see  page  286). 

Immediately  after  delivery  the  pulse  falls  to  some  extent,  but  the  diminution  is 
generally  followed  in  a  short  time  by  an  acceleration,  which  lasts  for  several  hours. 

In  healthy  women,  this  transient  acceleration  is  very  often  followed  by  a  second 
diminution  in  pregnancy.  Without  attempting  to  state  the  exact  proportion  of 
cases  in  which  retardation  is  observable,  I  will  only  remark  that  it  is  so  extremely 
common  as  to  be  found  almost  constant  when  sought  for  carefully. 

The  diminution  in  the  frequency  of  the  pulse  has  been  well  studied  and  described 
bv  II.  Blot,  in  a  memoir  of  which  we  give  an  analysis  (Archives  Generate  de  Mede- 
cine,  May,  18G4.) 

The  greatest  diminution  of  frequency  observed  by  M.  Blot,  was  thirty-five  beats 
per  minute.  "But,"  says  he,  "it  must  not  be  supposed  that  so  great  a  difference 
is  common,  —  for  I  have  met  with  it  in  but  three  cases.  Between  thirty-five  and 
sixty-live  beats  per  minute,  the  latter  of  which  we  regard  as  the  standard,  we  have 
observed  every  grade  of  diminution.  Two  numbers,  however,  forty-four  and  fifty- 
six,  have  impressed  us  by  their  relative  frequency." 

The  slowness  of  the  pulse  may  continue  from  one  to  twelve  days,  generally  last- 
ing longer  in  multiparas  than  in  primiparse.  In  the  latter,  it  rarely  continues 
longer  than  three  days,  whilst  in  the  former  it  is  often  observed  for  four,  six,  and 
seven  days. 

The  time  at  which  it  comes  on  varies  somewhat  in  different  women,  though  it 
generally  is  observable  within  twenty-four  hours  after  delivery.  In  the  twenty- 
four  hours  following  its  appearance,  the  slowness  of  the  pulse  increases;  then,  after 
remaining  for  a  time  stationary,  gradually  gives  place  to  the  rate  which  is  habitual 
to  the  woman. 

The  slowness  diminishes  and  sometimes  even  ceases  entirely  as  soon  as  the  breasts 
experience  the  congestion  which  precedes  the  secretion  of  milk.  Usually,  however, 
the  pulse  gradually  becomes  more  frequent.  We  shall  have  occasion  to  revert  to 
this  fact  when  we  come  to  treat  of  the  secretion  of  the  milk  and  what  is  known  is 
the  milk-fever. 

The  slowness  occurs  also  after  abortion  and  after  premature  delivery,  whether 
spontaneous  or  artificial. 

When  the  slowness  of  the  pulse  is  observed  in  a  newly  delivered  woman,  we  may 
feel  sure  that  she  is  in  a  perfectly  normal  condition,  so  that  in  respect  to  the 
prognosis  it  is  an  extremely  favorable  sign. 

In  a  lying-in  hospital,  the  frequency  of  the  diminution  of  the  pulse  in  proportion 


PHENOMENA    APPERTAINING    TO    THE    LYING-IN    STATE.         423 

to  the  number  jf  puerperal  women  indicates,  in  a  general  way,  an  excellent  sanitary 
condition:  its  rarity,  on  the  contrary,  should  excite  our  apprehension  of  an  un- 
healthy tendency  in  the  newly  delivered  inmates. 

The  cause  of  this  slowing  of  the  pulse  is  obscure.  It  would  seem,  however,  from 
the  sphygmographical  experiments  of  MM.  Blot  and  Marey,  that,  like  the  diminu- 
tion of  frequency  under  all  circumstances,  it  is  connected  with  a  certain  increase 
in  the  tension  of  the  arteries,  which  tension  the  authors  just  quoted  think  may  be 
explained  by  the  sudden  and  almost  entire  suppression  of  the  circulation  which 
existed  in  the  uterine  walls  during  pregnancy.  When  the  uterus  contracted,  the 
blood  which  previously  traversed  it  accumulated  in  the  arterial  system,  from  whence 
resulted  a  greater  tension  which  became  in  its  turn  an  impediment  to  the  ventricular 
systole,  giving  rise  to  the  temporary  diminution  in  frequency  of  the  pulse,  followed 
by  an  establishment  of  equilibrium. 

Whatever  the  explanation,  the  fact  is  both  established  and  shown  to  be  of  great 
clinical  importance.] 

Crede  has  shown  that  a  rise  of  temperature  may  take  place  at  any 
period  from  any  temporary  cause,  such  as  constipation,  mental  disturb- 
ance, errors  of  diet,  etc.  Should  there  be  a  rise,  however,  above  100 J  F., 
some  complication  would  naturally  be  expected. 

If  the  relaxed  walls  of  the  abdomen  be  examined  after  delivery,  the  womb 
is  felt  above  the  pubis  as  a  large  tumor,  which  henceforth  diminishes  in 
size.  In  thin  women,  particularly  those  who  have  often  had  children,  the 
womb  still  remains  at  the  end  of  two  weeks  about  two  fingers'  breadth  above 
the  pubis,  yet  the  fundus  in  primiparse,  more  especially  in  such  as  are  at  all 
inclined  to  embonpoint,  cannot  be  distinctly  felt  after  a  week;  and  by  the 
end  of  the  sixth  week  this  organ  has  nearly  regained  its  primitive  condition, 
being  still,  perhaps,  a  little  larger  than  usual. 

[The  diminution  of  the  bulk  of  the  uterus,  its  atrophy,  so  to  speak,  has  been 
studied  so  carefully  by  Dr.  Wieland,  who  noted  its  progress  day  by  day,  that  we 
think  we  cannot  do  better  than  quote  some  portions  of  his  excellent  thesis,  which 
are  of  interest  in  connection  with  the  subject  under  consideration. 

At  the  commencement  of  labor,  the  organ  has  generally  an  elevation  of  from 
eight  to  nine  inches  above  the  pubis,  and  from  six  and  a  half  to  seven  and  a  half 
inches  in  width.  When  the  clots  which  follow  the  exit  of  the  placenta  are  ex 
pelled,  the  uterus  is  found  to  have  assumed  a  spheroidal  form,  and  is  hard,  resisting, 
and  contracted.  Its  vertical  diameter  is  then  only  about  from  four  and  a  half  to 
five  inches,  and  its  transverse  diameter  from  three  and  a  half  to  four  inches.  After 
about  half  an  hour  and  during  the  first  few  hours  succeeding  delivery,  its  size 
increases  somewhat, — (vertical  diameter,  five  to  five  and  a  half  inches;  transverse 
diameter,  four  and  a  quarter  to  four  and  three  quarter  inches;)  but  thereafter  it 
diminishes  gradually  and  almost  uniformly.  On  the  second  day  the  decrease  in 
the  diameters  amounts  to  from  three-eighths  to  five-eighths  of  an  inch,  the  vertical 
then  being  often  rather  less  than  the  transverse.  On  the  third  day,  in  most  cases, 
little  change  is  observable  except  in  women  who  have  had  in  the  interval  of  the 
two  last  examinations  severe  after-pains,  accompanied  by  an  abundant  Lochia!  dis- 
charge when  the  contraction  takes  place.  Dr.  Wieland  observed  that  until  the 
middle  of  the  fourth  day  the  size  of  the  uterus  was  unchanged  but  seemed  softer 
and  less  regularly  rounded  in  form,  and  that  this  inactive  condition  always  coincided 
with  the  commencing  lacteal  secretion.  From  the  end  of  the  fourth  day  the  retro- 
cession of  the  organ  progressed  regularly  and  continuously.  The  distance  which 
then  separates  the  uterus  from  the  pubic  symphysis  varies  from  two  and  three- 
eighths  to  two  and  seven-eighths  of  an  inch,  and  in  exceptional  cases  only  is  it  less 


4  2  1  LABOR. 

During  each  of  the  following  days  the  observed  difference  varies  from  three-eighths 
to  three-sixteenths  of  an  inch. 

By  the  sixth  day  the  uterus  has  become  hard,  its  anterior  surface  less  convex, 
and  its  fundus  readies  from  an  inch  and  a  half  to  two  inches  above  the  superior 
strait.  Usually  not  before  the  tenth  day,  and  sometimes  not  until  the  eleventh,  has 
it  disappeared  behind  the  symphysis  pubis;  but  even  then,  if  the  abdominal  walls 
are  very  thin  upon  the  median  line,  the  fundus  may  be  felt  in  the  pelvic  cavity  by 
pressing  downward  with  the  bent  fingers. 

During  all  this  time  the  tendency  of  the  womb,  which  in  the  majority  of  cases 
(79  in  100)  'is  situated  to  the  right,  is  to  resume  its  position  in  the  median  line. 

The  organ,  however,  is  far  from  having  attained  its  primitive  condition,  even 
when  the  hand  is  unable  to  feel  it  through  the  abdominal  wall;  and  its  state  can 
be  determined  only  by  the  vaginal  or  rectal  touch. 

The  laxity  of  the  ligaments,  the  mobility  which  it  still  retains,  and  its  diminished 
size,  cause  it  to  settle  into  the  excavation,  so  that  its  inferior  segment,  still  con- 
siderably developed  (being  nearly  an  inch  and  a  half  or  two  inches  in  diameter), 
depresses  the  vaginal  cul-de-sac.  The  neck  is  lower  down  in  the  vagina,  and  the 
posterior  surface  of  the  organ  is  felt  to  be  hard,  convex,  and  of  a  size  which  can  only 
be  approximative^  determined.  The  absorption  seems  now  to  go  on  more  slowly, 
bo  that  no  sensible  difference  can  be  perceived  for  eight  or  ten  days  longer.  By 
this  time  its  volume  is  slightly  lessened,  there  is  less  depression  of  the  vaginal  cul- 
de-sac,  and  it  is  more  movable.  Finally,  in  women  whom  I  examined  three 
months  after  delivery,  the  original  condition,  as  respects  situation,  form,  direction, 
consistency,  and  mobility,  seemed  to  be  restored,  the  size  only  appearing  to  be 
somewhat  greater.  In  no  case  had  it  resumed  entirely  its  primitive  condition 
cither  by  the  sixth  week  or  the  second  month.     (Wieland.)] 

The  rapidity  with  which  the  uterus  after  delivery  tends  to  resume  the 
volume  and  dimensions  which  it  possessed  before  impregnation,  is,  to  say  the 
least,  quite  as  surprising  as  the  rapidity  with  which  it  underwent  its  enormous 
bypertropb.y  during  gestation.  An  examination  of  the  various  changes 
through  which  this  rapid  absorption  is  effected,  induced  M.  Retzius,  of  Copen- 
hagen, to  conclude  that  it  is  preceded  by  a  fatty  degeneration  of  the  mus- 
cular fibres.     The  same  observations  have  also  been  made  by  Kolliker. 

This  diminution  in  the  size  of  the  uterus  is  not  always  so  regularly  gradu- 
ated as  described,  for  when  the  contractility  of  the  tissue  has  been  feeble 
after  delivery,  the  Avails  of  the  uterus  often  preserve  a  considerable  thickness 
for  tour  or  five  days,  the  fundus  being  found  all  this  time  close  up  to  the 
umbilicus.  The  same  observation  may  be  made  at  a  still  later  period,  in 
cases  where  an  inflammation  of  the  peritoneum,  of  the  uterine  mucous  mem- 
brane, or  of  the  neighboring  organs  has  supervened.  Again,  it  happens  that, 
after  having  been  diminished,  its  volume  augments  anew,  for  some  hours,  at 
times,  even  for  a  day  or  two,  and  then  soon  returns  to  its  former  size.  I  can 
*x plain  this  circumstance  only  by  supposing  some  local  congestion,  which 
has  not  been  acute  enough  to  produce  an  active  hemorrhage,  but  whose 
action  has  been  limited  to  distending  and  engorging  the  uterine  vessels,  and 
consequently  to  increasing  the  thickness  of  the  walls;  or  this  abnormal 
volume  may  be  owing,  in  certain  cases,  to  the  presence  of  newly  formed 
coagula.  But,  however  that  may  be,  I  felt  bound  to  point  out  these  anoma- 
lies, to  prevent  the  inexperienced  practitioner  from  falling  into  error. 

[The  interna]  surface  of  the  uterus  alter  delivery,  has  lately  been  studied  care- 


PHENOMENA    APPERTAINING    TO   THE    LYING-IN    STATE.        425 

fully  by  MM.  Colin,  Kobin,  Pajot,  and  Behier.  Two  parts,  dissimilar  in  appear- 
ance, may  be  distinguished  in  it;  one  of  these,  which  is  extensive,  was  in  relation 
with  the  decidua  during  gestation;  the  other,  having  a  lesser  surface,  presents 
traces  of  the  insertion  of  the  placenta.  We  have  next  to  study  these  two  parts  in 
succession.] 

A  few  hours  after  delivery,  says  M.  Colin,  the  internal  surface  of  the 
w  )inb  is  covered  with  clots  of  hlood,  which,  upon  being  removed,  discover 
a  soft,  moist,  reddish  layer,  lining  the  whole  internal  surface  of  the  uterus, 
except  where  the  placenta  was  attached.  If  the  surface  be  scraped  with  the 
blade  of  a  scalpel,  a  layer  varying  in  thickness  from  the  one-eighth  to  the 
one-sixteenth  of  an  inch  may  be  raised  from  it.  This  layer,  which  increases 
in  thickness  towards  the  middle  and  fundus  of  the  organ,  is  of  a  reddish- 
gray  color  and  friable,  tearing  like  a  newly-formed  pseudo-membrane,  and 
even  giving  way  beneath  the  fingers.  Below  it  is  found  the  muscular  tissue, 
of  a  white  or  grayish  appearance,  entirely  distinct  from  this  layer,  and 
easily  recognized  by  its  clearer  hue,  the  appearance  of  fibres  and  their  trans- 
verse direction,  as  also  by  its  greater  consistency. 

It  is  now  demonstrated  that  this  membrane  is  formed  by  a  new  uterine 
mucous  membrane  in  process  of  regeneration  from  the  fourth  month  of  ges- 
tation.    (See  page  177.) 

At  the  upper  boundary  of  the  cavity  of  the  neck,  this  membrane  is  termi- 
nated by  an  irregular  edge  projecting  above  the  latter,  and  from  which  are 
put  forth  small  shreds  or  laminae,  from  one  to  three-sixteenths  of  an  inch  in 
length,  of  the  same  nature  as  the  layer  covering  the  wall  of  the  uterus. 

The  cavity  of  the  neck  contains  a  glutinous,  transparent,  and  slightly- 
reddish  mucus.  The  color  of  its  internal  surface  varies  greatly  according  to 
the  mode  of  death,  from  a  reddish-gray  to  a  blackish-brown.  The  thickness 
of  the  mucous  membrane  lining  the  cavity  of  the  neck  varies  from  the  one- 
thirty-second  to  the  one-sixteenth  part  of  an  inch  ;  it  is  very  moist  and  flex- 
ible, although  firm  and  torn  with  difficulty.  It  remains  intact,  and  does  not 
participate  in  the  exfoliation  which  that  of  the  body  undergoes. 

The  condition  of  the  mucous  membrane  at  a  period  still  more  remote  from 
delivery,  has  also  been  studied  by  M.  Colin.  Not  until  after  about  the  ninth 
day  are  epithelial  cells  found  upon  the  surface  of  the  uterine  mucous  mem- 
brane in  process  of  restoration.  Until  the  twentieth  day  its  tissue  is  com- 
posed chiefly  of  fusiform  bodies,  nuclei,  and  granules;  glands  and  numerous 
capillary  vessels  are  found  in  it  about  the  twentieth  day.  Thus,  from  the 
twenty-eighth  to  the  thirtieth  day,  the  membrane  has  assumed  a  rose-red  or 
grayish  color,  especially  in  the  vicinity  of  the  neck  ;  it  is  smooth,  moist,  and 
soft,  but  resists  the  action  of  a  stream  of  water,  though  it  may  be  scraped 
off  entirely  by  the  scalpel,  so  as  to  expose  the  muscular  fibres.  Numerous 
vessels,  whose  greatest  diameter  does  not  exceed  the  one-ninetieth  part  of 
an  inch,  proceed  from  the  muscular  tissues  and  ramify  ad  infinitum  in  its 
substance.  By  the  fortieth  day,  the  membrane  is  of  a  rather  deep-red  color, 
opaque,  and  of  about  the  one-thirty-second  part  of  an  inch  in  thickness,  toward 
the  fundus;  it  is  semi-transparent  and  thinner  in  the  lower  part  of  the  body, 
where  it  is  continuous  with  the  mucous  membrane  of  the  neck,  which  presents 
no  peculiarities.    It  is  soft,  and  easily  removed  by  the  back  of  a  scalpel.     It 


426  LABOR. 

is  traversed  by  a  very  close  network  of  capillary  vessels.  By  the  sixtieth 
day,  it  is  smooth,  gray,  and  supplied  with  small  vessels;  it  has  the  true  con- 
sistency of  a  mucous  membrane,  and  the  scalpel  removes  from  it  but  a  slight 
pellicle,  which  has  no  longer  the  pulpy  appearance  of  the  substance  detached 
from  it  at  an  earlier  period. 

This  new  mucous  membrane,  which,  according  to  M.  Robin,  begins  to  be 
formed  by  the  fourth  month  of  gestation,  is,  therefore,  after  delivery,  the 
seat  of  a  reparatory  process,  which  ends  in  the  completion  of  a  new  mucous 
membrane.  The  mucous  membrane  of  the  neck  is  not  thrown  oft";  it  is 
simply  hypertrophic'!  during  pregnancy,  and  after  delivery  continues  to 
exhibit  the  arbor  vihe,  though  of  a  somewhat  modified  form. 

The  point  of  attachment  of  the  placenta  is  marked  by  an  elevation, 
presenting  to  the  view  a  surface  mammilhited,  rounded,  anfractuous,  and 
projecting  to  the  extent  of  a  quarter  of  an  inch  .above  the  level  of  the  sur- 
rounding surface.  The  anfractuosities  are  tilled  up  with  coagulated  blood, 
which  is  removed  from  them  with  difficulty.     It  is  the  placenta  wound 

These  inequalities,  which  have  been  regarded  by  some  anatomists  as  tufts 
destined  to  dip  down  between  the  cotyledons  of  the  placenta,  are  due,  accord- 
ing to  Desormeaux,  to  the  excessive  distention  which  the  arteries  and  veins, 
the  last  especially,  have  undergone  during  pregnancy,  and  upon  the  slowness 
of  their  subsequent  retraction ;  though,  according  to  Velpeau,  they  are  owing, 
in  women  that  die  shortly  after  delivery,  to  the  swelled  and  fungous  charac- 
ter of  that  portion  of  the  internal  uterine  surface  which  corresponded  to  the 
placenta.  We  prefer  the  following  explanation,  given  by  M.  Jacquemier, 
viz. :  the  internal  muscular  layer  of  the  womb  is  perforated  in  all  the  space 
occupied  by  the  after-birth,  by  a  great  number  of  holes,  which  give  a  pecu- 
liar aspect  to  this  portion  of  its  inner  surface,  and  render  it  less  contractile 
than  at  other  parts;  and  consequently,  as  the  organ  retracts,  it  has  a  ten- 
dency to  project  into  its  cavity,  and  when  it  arrives  at  the  final  state  of 
repose,  a  tumor  is  formed,  which  is  ordinarily  larger  than  the  palm  of  the 
hand,  with  a  very  irregular  lacerated  surface,  spongy,  as  it  were,  in  charac- 
ter, and  often  standing  out  in  considerable  relief;  the  torn  utero-placental 
vessels  are  comprised  in  this  mass,  which  renders  them  tortuous  and  nearly 
inextricable.  But  whatever  the  explanation  may  be,  it  is  highly  important, 
adds  M.  Jacquemier,  to  bear  this  arrangement  constantly  in  mind,  for  an 
attentive  perusal  of  several  cases  of  artificial  delivery  of  the  after-birth, 
has  convinced  me  that,  in  those  instances,  the  tumor  formed  by  the  most  inter- 
nal layer  of  the  womb  was  mistaken  for  debris  of  the  placenta,  which  the 
medical  attendants  endeavored  ineffectually,  though  not  without  danger, 
lo  extract. 

[Rubin  has  shown  that  this  projecting  portion  is  formed  simply  by  the  utero- 
placental mucous  membrane,  which  remains  adherent  to  the  uterine  wall,  with  t lie 
exception  of  the  thin  superficial  layer  which  was  carried  away  by  the  placenta. 
(See  Decidua, and  Placenta.) 

The  retraction  of  the  uterus  after  delivery  diminishes  greatly  the  superficial  ex- 
tent of  this  part  of  the  mucous  membrane,  being  soon  reduced  to  a  diameter  of 
from  two  and  a  half  to  three  and  a  quarter  inches,  and  so  progressively.  At  firsi 
it  was  circular  in  form,  hut  Boon  becomes  irregularly  oval,  with  the  greater  diameter 


PHENOMENA    APPERTAINING   TO   THE    LYTNG-IN    STATE.        427 

corresponding  with  the  longer  diameter  of  the  uterus.  What  it  loses  in  length, 
however,  it  gains  in  thickness  by  the  contraction  of  the  organ.  A  few  days  aftei 
delivery,  it  has  a  thickness  of  from  five-eighths  to  six-eighths  of  an  inch,  and  in 
some  places  even  more.  At  the  same  time,  its  surface  becomes  folded  and  rough- 
ened, and  its  substance  brownish  or  reddish  ;  it  also  softens  gradually,  and  assumes 
a  pultaceous  or  mucous  consistence.  Its  projecting  and  irregular  edges  are  con 
tinuous  with  the  thin,  newly-formed  mucous  membrane  which  lines  the  remaindei 
of  the  uterus. 

It  is  not  uncommon  to  find  on  the  surface  of  the  part  just  described  vascular 
orifices  plugged  up  by  reddish  or  bleached  clots,  and  if  the  latter  be  traced  by  dis- 
section into  the  deeper  parts  of  the  membrane,  they  will  be  found  to  lead  into  the 
subjacent  uterine  sinuses.  The  cavernous  appearance  given  to  this  layer  by  the 
membranous  anastomoses  of  its  vessels  is  very  striking,  and  one  cannot  but  observe 
at  the  same  time  that  its  thickness  and  the  projections  which  it  forms  upon  the 
internal  surface  of  the  uterus  are  principally  due  to  the  clots  which  fill  and  distend 
the  sinuses  to  a  greater  or  less  extent.  If  the  latter  be  emptied,  the  intervals 
between  them  will  become  very  slight. 

The  clots  lose  their  color  and  lessen  gradually,  but  they  are  still  found  up  to  the 
twentieth  day  after  delivery,  and  often  much  later.  The  tissue  of  the  serotina  it- 
self atrophies,  and  finally  becomes  continuous  with  and  indistinguishable  from  the 
newly-formed  mucous  membrane.  In  some  women,  however,  the  mucous  membrane 
remains  for  several  years  both  thicker  and  more  projecting  at  this  point  than  else- 
where. It  was  a  mistake,  therefore,  to  suppose,  as  has  been  heretofore  done,  that 
the  serotina  is  carried  away  with  the  placenta,  or  that  it  is  exfoliated  and  eliminated 
during  the  continuance  of  the  lochial  discharge.     (Robin.) 

In  autopsies  of  puerperal  fever  cases,  the  layer,  with  a  reddish,  flocculent,  black- 
ish and  pultaceous  appearance,  formed  by  the  serotina,  has  often  been  mistaken  by- 
persons  not  fully  acquainted  with  what  had  taken  place  previously,  for  portions  of 
the  placenta  remaining  adherent  to  the  uterus,  and  then  in  course  of  decomposition. 

To  recapitulate:  At  the  moment  of  labor  there  is  already  present  a  newly- 
formed  but  very  thin  mucous  membrane  between  the  muscular  layer  of  the  uterus 
and  the  parietal  decidua.  The  new  membrane  makes  its  appearance  at  the  fourth 
month,  but  does  not  continue  to  grow  between  the  muscular  layer  and  the  utero- 
parietal  mucous  membrane.  Finally,  when  the  placenta  is  detached,  the  greater 
part  of  the  serotina  remains  adherent  to  the  uterus.  This  utero-placental  mucous 
membrane  does  not,  therefore,  deserve  the  name  of  decidua,  inasmuch  as  it  continues 
and  diminishes  gradually  in  thickness  until  its  surface  corresponds  with  that  of  the 
recrudescent  mucous  membrane.] 

Professor  Stoltz  has  studied  the  modifications  that  occur  in  the  neck  of 
the  uterus,  after  the  delivery,  with  a  great  deal  of  care,  and  we  extract  the 
following  passage  from  his  excellent  thesis  on  this  subject:  "As  soon  as  the 
child  is  born,  the  cervix  is  partly  formed  anew,  but  it  is  soft,  short,  wide, 
and  irregular,  and  one  or  more  fingers  can  easily  be  made  to  penetrate  it; 
the  internal  orifice  oilers  the  greatest  resistance,  as  is  proved  when  an 
attempt  is  made  to  introduce  the  hand  into  the  womb,  for  it  enters  with 
considerable  difficulty,  and  only  when  this  orifice  has  been  progressively 
dilated.  The  latter  is  sometimes  so  contracted  as  to  induce  inexperienced 
persona,  who  endeavor  for  the  first  time  to  carry  the  hand  up  into  the 
womb,  to  believe  they  have  succeeded,  when  in  fact  they  have  only  reached 
the  dilated  vagina,  where  they  find  a  large  cavity,  but  no  opening  to  get 
any  further,  and  the  clots  of  blood,  then  collected  at  the  upper  part  of  the 
vagina  and  around  the  cervix,  add  still  more  to  this  confusion.' 


428  LABOR. 

The  internal  orifice,  formed  after  the  expulsion  of  the  child,  offers  hut 
little  resistance;  and,  consequently,  it  has  scarcely  occasion  to  dilate  again 
for  the  passage  of  the  placenta,  as  it  yields  readily ;  and  when  the  delivery 
of  the  after-hirth  is  effected,  the  womb  contracts,  and  the  neck  becomes 
longer  and  more  consistent ;  although  it  must  again  open  several  times  to 
permit  the  numerous  clots  of  blood  to  escape.  During  the  lying-in,  it 
gradually  returns  to  its  natural  size;  sometimes,  even,  it  is  longer;  but  it 
acquires  the  ordinary  disposition  more  or  less,  as  it  regains  its  proper  con- 
sistence, and  by  the  end  of  the  first  month  it  generally  exhibits  about  the 
same  dimensions  as  it  had  prior  to  gestation  ;  at  times,  however,  it  is  a  little 
shortened,  and  the  consistence  is  nearly  as  firm  as  usual,  although  the  infe- 
rior part  has  seemed  to  us  rather  more  softened.  It  no  longer  presents  a 
conical  shape,  but  is  more  cylindrical,  from  the  fact  of  the  summit  having 
become  larger.  As  a  general  rule,  the  scars  on  the  lips  are  proportionably 
more  numerous  as  the  patient  has  had  a  greater  number  of  children,  and 
her  labor  has  been  more  tedious.  The  transverse  fissure  is  deeper  and 
more  angular ;  and,  in  such  women,  the  upper  part  of  the  cervix  is  some- 
times larger  than  the  base,  though  it  is  much  shorter  than  usual,  and  at 
limes  is  divided  into  two  lips  that  are  more  or  less  flat,  broad,  and  unequal, 
and  the  anterior  of  which  is  longer  than  the  posterior;  indeed,  in  some 
cases  the  latter  seems  to  have  been  altogether  destroyed,  while  in  others  it 
is  well  marked,  and  the  anterior  one  is  scarcely  perceptible.  In  fact,  almost 
as  many  varieties  exist  on  this  point  as  there  are  different  subjects. 

The  vagina  becomes  shorter,  and  the  ridges  that  were  effaced  during  the 
last  stage  of  labor,  gradually  but  slowly  reappear,  and  the  orifice  of  this 
canal,  and  the  vulva,  also  regain  their  primitive  condition.  At  first,  the 
labia  externa,  as  well  as  the  perineum,  are  thin  and  distended,  and  the  pos- 
terior part  of  the  contour  of  the  vulva  is  flabby,  wrinkled,  and  projecting 
outward.  Sometimes  the  epidermis  is  fretted,  at  others,  actual  lacerations 
are  found,  which  produce  a  smarting  sensation ;  and  as  to  the  fourchette,  it 
is  almost  inevitably  torn  in  the  first  labor. 

The  broad  ligaments  seem  to  re-form  by  the  approximation  of  their  two 
constituent  layers,  while  the  round  ligaments  gradually  become  shortened 
and  retracted. 

The  abdominal  muscles  and  integuments,  which  were  at  first  soft  and 
flabby,  and  exercised  but  a  very  imperfect  pressure  on  the  viscera  and  ves- 
sels contained  in  their  cavity,  again  retract;  although  this  process  is  very 
often  incomplete  in  women  of  a  soft  fibre,  or  who  have  had  many  children. 

This  slow  and  gradual  retraction  of  the  uterus  takes  place,  in  some  in- 
stances, without  the  least  pain,  and  without  the  knowledge  of  the  patient ; 
but  it  more  generally  becomes  intermittent  and  distressing,  and  as  the  suf- 
ferings the  women  then  experience  have  a  great  analogy  to  those  of  child- 
birth, they  are  called  the  after-pains.  At  the  same  time,  a  more  or  less 
abundant  discharge  takes  place  from  the  vulva,  consisting  at  first  of  pure 
blood,  then  of  blood  mixed  with  a  white  fluid,  and,  lastly,  of  a  white  sero- 
purulent  liquid  ;  and  these  discharges  have  received  the  name  of  the  lochia 
Finally,  a  function  altogether  new  sets  in,  in  the  course  of  the  first  few  days, 
which   may  be  considered  as  the  complement  of  the  puerperal  functions; 


PHENOMENA    APPERTAINING    TO    THE    LYING-IN    STATE.        429 

this  is  the  milk  secretion,  whose  onset  is  attended  by  certain  general  phe- 
nomena, which  are  ordinarily  described  under  the  term  of  the  milk  fever , 
we  shall  therefore  have  to  examine,  in  turn,  these  three  principal  phenom- 
ena of  the  lying-in  state. 

§  1.  Of  the  After-Pains. 

The  after-pains  are  certainly  occasioned  by  the  contraction  of  the  womb , 
to  be  satisfied  on  this  point,  it  is  only  necessary  to  place  the  hand  over  the 
hypogastric  region,  when  we  will  ascertain  that  the  uterus  becomes  harder 
just  at  the  moment  when  the  patient  complains  the  most.  These  pains  are 
much  more  frequent  and  intense  in  women  who  have  borne  many  children 
than  in  primiparse ;  as,  also,  after  an  easy  than  after  a  long  and  painful 
labor;  and  when  the  womb  incloses  some  foreign  body,  such  as  coagula,  or 
a  portion  of  the  membranes  or  placenta,  than  when  its  cavity  is  entirely 
empty.  Now,  all  these  differences  in  character  will  be  readily  compre- 
hended, if  the  reader  will  only  bear  in  mind  that  the  object  of  the  contrac- 
tions is  to  express  from  the  uterine  parietes  those  liquids  with  which  the 
walls  are  still  engorged  after  the  delivery,  and  to  expel  from  its  cavity  all 
the  foreign  substances  contained  therein ;  that,  in  very  prompt  labors,  the 
urgan,  from  being  evacuated  too  rapidly,  does  not  retract  so  perfectly  as  it 
ought,  and  allows  the  blood  to  coagulate  and  accumulate  in  its  interior, 
and  that  the  very  feeble  contractility  of  its  tissue  force*  out  but  very  im- 
perfectly the  fluids  remaining  in  the  thickness  of  the  walls. 

The  pains  generally  commence  soon  after  the  delivery,  being  at  first  feeble 
an  J  distant,  then  more  frequent  and  painful;  and,  at  the  moment  of  their 
occurrence,  the  uterine  globe  retracts,  becomes  harder,  more  resistant,  and 
sometimes  even  seems  to  rise  up,  by  resting  on  the  posterior  plane  of  the 
abdomen,  as  a  point  d'appui,  and  projecting  in  the  form  of  a  globular  tu- 
mor through  the  walls  of  the  abdomen.  The  escape  of  the  lochia  is  ordi- 
narily more  abundant  towards  the  end  of,  or  just  after  each  pain,  and  nut 
un frequently  a  few  small  coagula  come  away  from  the  vulva ;  but  where 
the  uterus  contains  a  large  one,  the  pains  constantly  increase  in  force  and 
frequency,  until  it  is  expelled,  after  which  they  again  diminish.  In  most 
cases,  they  cease  during  the  milk  fever,  though  they  may  continue  for  the 
first  seven  or  eight  days.  They  are  very  commonly  excited  by  putting  the 
child  to  the  breast.  Sometimes  they  return  after  having  entirely  disap- 
peared, are  followed  by  the  discharge  of  a  little  blood  from  the  vulva,  or 
the  expulsion  of  a  clot,  or  of  a  portion  of  membrane  that  has  remained  in 
the  uterus,  and  then  everything  returns  to  its  natural  condition.  They  are 
sometimes  so  severe  as  to  extort  cries  from  the  patient,  and  some  women 
insist  that  they  suffer  more  from  them  than  from  the  labor  pains. 

As  regards  the  diagnosis,  it  is  highly  important  to  distinguish  the  after- 
pains  from  those  caused  by  peritoneal  inflammation,  but  fortunately  this  is 
not  very  difficult;  for  however  strong  the  after-pains  may  be,  they  arc  gen- 
erally intermittent,  and  are  separated  by  an  interval  of  variable  duration  ; 
besides,  the  distress  attendant  upon  them  is  rather  alleviated  than  augmented 
by  pressure,  and  a  rather  more  abundant  lochia!  discharge  accompanies  or 
follows  them.     While  they  last,  there  is  an  absence  of  febrile  movement; 


430  LABOR. 

finally,  when  the  child  seizes  the  nipple,  especially  if  the  latter  is  the  seat 
of  any  ulceration,  the  sufferiag  thereby  caused  most  frequently  brings  on  an 
after-pain,  and  this  circumstance  alone  has  often  sufficed  to  make  them  re- 
appear, even  after  a  suspension  of  several  hours.  When  existing,  these,  dif- 
ferential characters  are  quite  sufficient  to  distinguish  them,  but  unhappily 
they  are  not  always  so  well  marked;  for,  where  they  are  very  acute,  or  fol- 
low each  other  in  rapid  succession,  they  are  accompanied  by  fever  and  sharp 
pains  in  the  hypogastrium.  But  even  then,  there  is  always  a  remission, 
which,  conjoined  with  the  absence  of  the  other  signs  of  peritoneal  inflamma- 
tion, may  aid  in  determining  their  character. 

Dr.  Dewees  states  that  he  had  several  times  an  opportunity  of  observing 
a  singular  pain  which  was  manifested  almost  immediately  after  the  delivery, 
and  vet  was  altogether  different  from  the  ordinary  after-pains.  It  is  a  very 
acute  pain,  referred  by  the  patients  to  the  lower  part  of  the  sacrum  and 
coccyx.  It  commences  as  soon  as  the  child  is  born,  and  continues  without 
interruption,  and  of  a  frightful  intensity.  It  is  declared  by  the  patient  to 
be  vastly  more  insupportable  than  the  after  pains,  for  it  is  quite  as  violent, 
besides  being  constant ;  the  latter  character  serving  as  a  ready  means  of  dis- 
tinguishing it.  Camphor  and  opium  appeared  to  him  the  most  successful 
means  of  relieving  it. 

The  after-pains,  of  which  we  have  just  spoken,  are  sometimes  so  severe  as 
to  claim  the  attention  of  the  physician,  and  although  they  may  be  useful 
when  caused  by  the  retention  of  a  foreign  body,  they  are  so  annoying,  that 
it  is  certainly  advisable  to  endeavor  to  prevent  them.  Dewees  states  that 
this  may  often  be  effected  by  observing  the  following  precautions:  1.  Do 
not  rupture  the  membranes  before  the  neck  is  completely  dilated ;  2,  after 
the  head  is  born  make  no  tractions,  but  allow  the  uterus  to  expel  the  shoul- 
ders and  trunk  ;  3,  do  not  extract  the  placenta  until  the  womb  is  thoroughly 
contracted  ;  4,  after  the  placenta  is  delivered,  excite  the  womb  so  as  to  oblige 
the  muscular  fibres  to  contract  as  much  as  possible.  It  is  evident  that  all 
these  measures  have  for  their  object  to  insure  the  slow  and  complete  con- 
traction of  the  walls  of  the  uterus,  in  proportion  as  its  contents  are  expelled. 

In  the  cases  of  women  who  have  suffered  much  from  after-pains  in  pre- 
vious confinements,  I  have  made  it  a  practice  to  administer  a  fewr  doses  of 
ergot  immediately  after  delivery,  with  the  effect,  I  have  thought,  of  pre- 
venting their  occurrence  in  many  cases,  or  at  least  of  lessening  their  violence. 
When  the  womb  contracts  feebly,  it  has  seemed  to  me  of  advantage  to  add 
pressure  upon  the  uterus  to  the  use  of  the  ergot.  This  is  done  by  means  of 
the  ordinary  bandage,  and  made  more  effectual  by  placing  a  compress,  formed 
of  one  or  two  folded  towels,  upon  the  fundus  of  the  organ. 

If  the  after-pains  are  feeble,  nothing  need  be  done ;  if,  however,  they  are 
very  violent,  the  physician  should  interpose.  Provided  the  patient  has  not 
suffered  from  hemorrhage,  or  been  threatened  with  it,  we  may  begin  by 
placing  warm  and  emollient  cataplasms  upon  the  abdomen.  Lotions  con- 
taining laudanum  may  be  used  upon  the  belly,  and  the  cataplasm  may  be 
wet  with  the  same  substance.  An  injection  may  also  be  given  of  from 
twenty  to  forty  drops  of  Sydenham's  laudanum,  in  as  small  an  amount  of 
vehicle  as  possible.    Dewees  professes  to  have  derived  great  advantage  from 


PHENOMENA    APPERTAINING    TO    THE    LYING-IN   STATE.        431 

a  camphor  mixture,  consisting  of  a  drachm  of  camphor  to  six  ounces  of 
vehicle,  a  tablespoonful  to  be  taken  every  hour  or  two.  When  the  mixture 
disagrees  with  the  patient,  ten  grains  of  finely-powdered  camphor,  every 
hour  or  two,  mixed  in  a  little  syrup  of  any  kind,  may  be  substituted  for  the 
julep  jnst  mentioned.  When  the  after-pains  are  accompanied  by  signs  of 
general  plethora,  blood  may  be  taken  from  the  arm.  Finally,  should  there 
be  cause  to  suspect  the  presence  of  large  clots  or  portions  of  the  membranes 
in  the  cavity  of  the  uterus,  one  or  two  fingers  may  be  introduced  within  the 
neck,  in  order  to  seize  them,  or  at  least  to  bring  about  their  expulsion.  These 
are,  perhaps,  the  only  circumstances  under  which  the  use  of  ergot,  so  highly 
vaunted  by  Crozat  and  Velpeau  as  a  remedy  for  after-pains,  is  likely  to  be 
successful. 

§  2.  Op  the  Lochia. 

Of  all  the  various  excretions  that  take  place  after  the  delivery,  the  lochia 
are  certainly  the  most  interesting  to  us  as  practitioners.  This  name  is  applied 
to  the  matters  that  escape  from  the  vulva  during  all  the  period  from  the 
delivery  of  the  after-birth  until  the  womb  has  regained  its  normal  size  and 
consistence.  Immediately  after  the  delivery  of  the  placenta,  and  the  escape 
of  the  accompanying  blood,  all  further  sanguineous  discharge  becomes  tem- 
porarily suspended,  probably  because  the  blood  that  transudes  from  the 
surface  of  the  womb  accumulates  in  the  cavity  of  that  organ ;  but  the  pure 
fluid  soon  begins  to  flow  again,  although,  in  the  course  of  twelve  or  fifteen 
hours,  it  loses  its  consistence,  and  its  color  becomes  lighter,  and  after  a  short 
time  it  is  changed  into  a  bloody  serosity.  At  the  expiration  of  the  first  day, 
the  fluid  secreted  contains  only  about  one-third  part  of  red  globules  ;  the  other 
elements  consisting  of  white  globules  in  rather  smaller  proportion,  and  very 
numerous  epithelial  cells.  The  suspending  fluid  is  sprinkled  with  grayish 
molecular  granules  and  granulations  of  fatty  matter.  After  the  second  day, 
the  proportion  of  white  globules  increases,  and  the  red  ones  diminish  or  even 
disappear.  The  secretion  of  milk  soon  commences,  and  then  the  flow  of  the 
lochia  is  either  diminished  or  entirely  suspended.  When  it  is  over,  the  bloody 
discharges  reappear,  and  continue  during  the  four  or  five  succeeding  days, 
though  with  characters  varying  greatly  in  different  individuals :  thus,  in 
some  women,  those  especially  who  menstruate  profusely,  they  appear  with 
the  same  characters,  quantity  excepted,  as  before  the  milk  fever.  They  are 
still  composed  of  pure  blood,  which  sometimes  contains  numerous  small  clots  ; 
with  the  majority,  however,  they  become  more  and  more  serous,  though  still 
exhibiting  here  and  there  some  bloody  streaks,  or  perhaps  are  slightly  tinged 
by  the  blood,  the  quantity  of  which  diminishes  every  day.  it  usually  disap- 
pears altogether  about  the  eighth  day;  the  lochia  being  thenceforth  coin- 
posed  of  a  more  or  less  consistent  yellowish-white  liquid,  and  they  thus 
continue  for  two  or  three  weeks  or  a  month ;  though  in  some  women,  wdio  do 
not  nurse,  they  do  not  pass  off  until  the  menses  reappear,  that  is,  in  about 
six  weeks  or  two  months  after  the  delivery. 

These  discharges  have  been  divided,  according  to  their  color,  into  the 
sanguinoleirf,  the  serous,  and  the  milky,  puriform.,  or  purulent  lochia.  As 
the  uterus  retracts,  its  walls  gradually  disgorge  the  fluids  they  had  imbibed, 


432  LABOR. 

and  these  naturally  run  towards  its  central  cavity.  So  long  as  the  large 
venous  canals  in  its  substance  are  aol  empty,  the  discharge  consists  of*  pure 
blood;  somewhat  later,  it  is  composed  of  serum,  together  with  the  detritus 
of  the  ovum  and  the  mucosities  of  the  orpin;  and  still  later,  a  true  suppu- 
rative irritation  is  established,  the  products  of  which,  analogous  in  some 
respects  to  the  non-contagious  discharges  of  the  urethra,  constitute,  in  a 
great  measure,  the  white  or  the  purulent  issue. 

The  lochia  have  a  peculiar  odor,  called  gravis  odor  puerperii,  which  varies 
in  Strength  according  to  the  individual  and  her  habits  of  cleanliness;  and 
to  this  is  also  added  the  scent  from  the  perspiration  and  the  milk,  which 
latter,  distilling  from  the  breast,  is  imbibed  by  her  garments  and  turns  sour. 
Sometimes  the  lochia  become  fetid,  and  where  this  circumstance  is  not  owing 
to  slovenliness,  it  is  always  an  unfavorable  sign,  since  it  most  generally 
announces  that  coagula  or  some  other  foreign  substances  are  putrefying  in 
the  uterus  ;  and  where  the  lochial  fluid  has  the  color  of  coffee-grounds,  and 
a  cadaverous  smell,  it  is  almost  uniformly  an  evidence  of  the  existence  of 
an  inflammation  of  the  womb  or  vagina,  which  has  terminated  in  gangrene. 
Again,  whenever  the  patient  is  afflicted  with  carcinoma  uteri,  the  discharges 
resemble  the  washings  ()f  flesh,  and  have  a  very  nauseous  smell.  In  all  such 
cases  aromatic  injections,  infusions  of  elder  or  chamomile  flowers,  which 
are  rendered  more  useful  by  adding  some  disinfecting  fluid,  should  be  made 
several  times  a  day. 

The  lochia  are  also  very  variable  in  quantity  and  duration,  though  we 
may  state,  as  a  general  rule,  that  the  patient  soils  ten  or  twelve  napkins  in 
the  course  of  the  first  twenty-four  hours,  eight  on  the  second  day,  six  on  the 
third,  four  on  the  fifth,  and  two  on  the  following  days.  After  the  milk 
fever  is  over,  the  flow  diminishes  more  and  more,  its  amount  being  usually 
proportionate  to  that  of  the  menstrual  evacuation.  It  is  more  copious  in 
women  who  have  borne  many  children,  or  who  make  use  of  an  overnour- 
ishing  or  a  heated  regimen,  and  in  those  who  do  not  nurse.  The  sanguineous 
discharges  vary  much  in  amount  during  the  first  days,  according  to  the  force 
of  retraction  with  which  the  uterine  walls  were  endowed  immediately  after 
or  during  the  delivery  of  the  after-birth  ;  thus,  at  times,  they  are  very 
copious,  frequently  coinciding  with  a  considerable  development  of  the  organ  ; 
and  in  such  cases  I  have  known  the  womb  to  continue  as  high  up  as  the 
umbilicus  for  several  days  after  the  delivery. 

This  condition,  which  Leroux  calls  humoral  engorgement,  depends,  in  his 
estimation,  on  the  fact  that  the  vessels  and  pores  of  the  womb,  from  being 
distended  with  blood,  do  not  become  empty  as  soon  as  usual,  because  the 
contractility  of  tissue  is  not  then  active  enough  to  expel  it;  for  the  walls  of 
the  uterus  constitute  a  true  sponge,  whose  meshes  are  composed  of  muscular 
fibres,  and  which  must  retract  forcibly  so  as  to  express  all  the  liquids  con- 
rained  in  t'ne  vessels  and  vacuities  which  they  form  ;  hence,  if  this  contraction 
is  not  strong  enough,  the  parietes  remain  engorged,  and  preserve  an  abnor- 
mal thickness,  which  singularly  augments  the  whole  volume  of  the  uterus, 
although  its  cavity  may  be  entirely  effaced.  Soon,  however,  the  contractile 
action  of  the  tissue  is  aroused,  and  the  muscular  fibres  forcibly  compress 
and  flatten  the  vessels  that  ramify  between  them,  and  thus  force  the  liquids 


PHENOMENA    APPERTAINING    TO   THE    LYING-IN    STATE.         133 

which  had  hitherto  remained  there  to  discharge  into  the  cavity  of  the  organ, 
whence  they  flow  towards  the  exterior  in  considerable  quantities.  This  dis- 
charge might  very  readily  be  mistaken  for  a  flooding,  occasioned  by  a  reten- 
tion of  some  part  of  the  after-birth,  or  of  voluminous  coagula,  the  more 
especially  as  it  is  accompanied  at  times  by  sharp  after-pains  ;  but  if  one  fingi  i 
can  then  be  introduced  into  the  uterus,  the  accoucheur  will  ascertain  thai  it 
contains  no  foreign  substance,  and  by  placing  the  other  hand  at  the  same 
time  on  the  hypogastric  region,  he  will  easily  satisfy  himself  that  the  unusual 
size  of  the  organ  depends  only  on  the  engorgement  of  its  walls.  In  these 
cases,  there  is  nothing  to  be  done,  as  the  sanguineous  discharge  is  itself  the 
best  remedy  ;  for  it  slowly  empties  the  uterine  texture,  diminishes  the  after- 
pains,  and  the  womb  gradually  returns  to  its  normal  size. 

This  slowness  of  the  retraction  also  prolongs  the  flow  of  the  sanguineous 
lochia,  and  the  same  result  is  observed  whenever  one  of  the  layers  of  the 
uterus  or  its  enveloping  cellular  tissue  is  affected  with  inflammation.  Indeed, 
we  can  readily  understand  that  from  this  sluggishness  of  the  uterine  fibres, 
this  defect  of  reaction,  as  Leroux  called  it,  to  a  more  or  less  perfect  inertia 
of  the  womb,  there  is  but  a  single  step,  and  that  a  secondary  hemorrhage 
might  result  from  the  absence  of  contractility,  if  it  were  carried  to  the  extent 
of  relaxation. 

[The  time  at  which  the  lochia  assume  a  purulent  form  is  also  liable  to  remark- 
able variations.  In  thirty-seven  cases  observed  by  M.  Behier,  in  which  everything 
was  favorable,  it  occurred  on  the  third  day  nine  times,  on  the  fourth  day  four  times, 
on  the  fifth  day  ten  times,  on  the  sixth  day  six  times,  and  from  the  seventh  to  the 
tenth  day  seven  times.  Finally,  in  one  case,  in  the  most  auspicious  condition,  the 
lochia  became  decidedly  purulent  only  on  the  sixteenth  day.  (Behier,  Clinique 
Mfrlicale.)] 

Lactation  lessens  the  duration  and  amount  of  the  lochia.  Some  women 
have  them  for  a  few  hours  only  (Van-Swieten),  and  others  have  none  at  all 
(Millot).  An  instance  of  the  latter  kind  came  under  my  notice  quite 
recently  (1855),  in  the  case  of  the  young  wife  of  a  medical  friend.  After 
an  easy  and  happy  labor,  the  lochia  were  almost  completely  suppressed.  She 
hardly  lost  a  few  spoonfuls  of  blood  within  the  first  twenty-four  hours;  after 
the  second  day  there  was  no  discharge  whatever,  and  the  husband,  who  ex- 
amined the  linen  daily  with  the  greatest  care,  assured  me  that  he  was  unable 
to  detect  the  slightest  evidence  of  lochial  discharge.  Everything  went  on 
well  during  the  lying-in,  with  the  exception  of  a  very  fetid  odor  from  the 
genital  parts  during  the  first  seven  or  eight  days.  After  satisfying  ourselves 
that  there  was  no  foreign  substance  in  the  uterus,  we  recommended  the  use 
of  injections,  frequently  repeated,  and  all  passed  off  well.  This  young  lady 
had  been  delivered  once  before,  on  which  occasion  she  had  a  perfectly  regular 
lochial  discharge. 

In  a  case  observed  by  Bruckmann,  and  quoted  by  Velpcau,  the  lochia 
were  substituted  by  haematemesis. 

In  some  instances,  the  sanguineous  lochia  are  prolonged  far  beyond  the 

usual   term  ;  while  in  others  they  reappear  at  various   intervals,  but  this 

latter  circumstance,  in  the  absence  of  inflammation  of  the  uterus  or  of  its 

appendages, is  ordinarily  owing  to  some  error  in  regimen, more  especially  to 

lis 


13-t  LABOR. 

getting  up  too  soon  ;  and,  therefore,  the  best  plan  is  to  persuade  the  patient 
to  remain  in  bed.  In  the  course  of  a  short  time  the  lochia  cease  their  con- 
tinual flow,  and  intervals  of  several  hours  of  duration  are  observed  at  first, 
then  of  a  day,  and  sometimes  of  two  days. 

"When,  in  spite  of  this  precaution,  the  bloody  discharge  continues  for  two 
or  three  weeks  after  labor,  its  cause  should  be  sought  for  in  a  local  alteration 
of  the  uterus  and  of  the  neighboring  parts,  or  else  in  the  general  condition 
of  the  patient.  Thus,  it  is  not  unusual  for  it  to  be  kept  up  by  a  circum- 
scribed peritoneal  inflammation,  an  inflammation  of  the  uterine  mucous 
membrane,  a  chronic  or  acute  engorgement  of  one  or  both  ovaries,  or  a 
phlegmon  of  the  broad  ligaments,  of  the  iliac  fossa,  or  of  the  cellular  tissue 
surrounding  the  uterus. 

It  is  important  to  diagnose  these  various  affections  from  the  outset,  as  it  is 
they  which  should  be  attacked,  in  order  to  stop  the  discharge,  which  is  here 
but  a  symptom  of  the  disease. 

The  continuance  of  red  discharges  is  connected,  perhaps,  more  frequently 
with  ulcerations  of  the  neck  of  the  uterus,  having  their  origin  in  many  cases 
in  the  lacerations  which  occur  during  labor,  and  the  cicatrization  of  which 
is  prevented  by  circumstances  which  elude  our  detection.  When,  therefore, 
it  is  certain  that  no  symptom  of  engorgement  or  inflammation  in  the  pelvic 
or  hypogastric  region  is  present,  the  patient  should  be  examined  with  the 
speculum,  taking  care  to  separate  the  lips  of  the  neck  with  the  valves  of  the 
instrument,  wheu  very  often  a  fungous  and  bleeding  ulceration  will  be  dis- 
covered either  within  the  cavity  of  the  neck  or  upon  the  os  tincae.  The  only 
means  of  arresting  the  discharge  consist  in  cauterizations  with  nitrate  of 
silver  or  acid  nitrate  of  mercury,  and  even,  if  the  fungosities  are  very  pro- 
jecting, with  the  actual  cautery.  In  some  cases,  it  is  necessary  to  repeat  the 
cant cii /ution  several  times. 

Amongst  the  causes  of  these  anomalous  lochial  discharges,  should  be 
reckoned  a  local  irritation  sustained  by  obstinate  constipation.  Here  the 
use  of  purgatives  is  demanded. 

Sometimes  no  lesion  can  be  discovered,  but  the  discharge  seems  evidently 
to  be  connected  with  an  over-excited  condition  of  the  entire  organism.  This 
condition  is  indicated  by  heat  of  the  skin,  fulness  of  pulse,  some  febrile 
movement  towards  evening,  and  disturbed  sleep.  Notwithstanding  the  ap- 
parent weakness  of  the  patient,  great  care  should  be  taken  in  reference  to  the 
use  of  tonics,  which,  unfortunately,  are  too  often  employed ;  a  moderate 
antiphlogistic  treatment,  on  the  contrary,  is  the  one  indicated.  A  small 
bleeding  from  the  arm,  mild  laxatives,  and  a  restricted  vegetable  diet,  might 
be  directed  with  advantage.  Stimulating  or  even  tonic  drinks  should  be 
proscribed,  and  only  after  the  general  irritation  shall  have  been  quieted,  is 
it  proper  to  endeavor  to  increase  the  strength  of  the  patient  by  the  appro- 
priate means. 

In  some  rare  cases,  however,  the  abundance  and  persistence  of  the  bloody 
discharge  se<  m  to  be  sustained  by  the  general  debility.  The  absence  of  the 
g  aeral  symptoms,  just  now  mentioned,  allow  of  recourse  being  had  imme- 
diately to  a  tonic  treatment  ;  then  it  is  that  infusions  of  cinchona  and  sul- 
phate of  in»n  are  capable  of  rendering  effectual  services.  (See  in  Tart  Fifth 
the  article  devoted  to  Secondary  Hemorrhage.) 


PHENOMENA    APPERTAINING    TO    THE    LYING-IN    STATE.       435 

The  white  or  purulent  lochial  discharges  sometimes  become  very  profuse, 
and  have  at  the  same  time  an  exceedingly  disagreeable  odor.  The  discharge 
is  no  longer  covered  with  blood,  but  appears  as  a  reddish  water  flowing  in 
large  quantity,  and  sometimes  even  escaping  in  gushes.  They  are  occasion- 
ally so  acrid  as  to  inflame  the  parts  over  which  they  flow.  The  patients  are 
almost  always  much  weakened  by  the  evacuation,  and  their  general  health 
evidently  demands  the  use  of  tonics.  The  irritated  parts  should  be  washed 
frequently  with  warm  water,  and  injections  of  infusion  of  chamomile  flower-, 
afterwards  made  rather  more  astringent,  should  be  thrown  into  the  vagina 
five  or  six  times  a  day.  A  few  spoonfuls  of  chloride  of  soda  might  be  added 
with  advantage.  [Carbolic  acid  3i.  ad  Oj.  is  at  the  present  time  most  fre- 
quently used.] 

These  purulent  lochia,  also,  sometimes  continue  long  after  the  usual  period 
of  their  cessation.  This  circumstance  is  sometimes  connected  with  some  one 
of  the  causes  mentioned  as  productive  of  the  anomalous  persistence  of  the 
bloody  discharge,  though  it  has  oftener  seemed  to  me  to  be  the  result  of  a 
catarrhal  metritis  or  peri-uterine  phlegmon.  Both  these  affections  may 
hinder  the  gradual  retraction  of  the  uterus,  which  may  remain  of  consider- 
able size  for  a  month  or  six  weeks  after  delivery.  Large  flying  blisters  upon 
the  abdomen,  frequent  alkaline  baths,  and  bleeding  from  the  arm,  when 
there  is  fever  and  the  strength  permits  it,  have  appeared  to  me  to  be  the 
most  effectual  under  these  circumstances. 

The  suppression  of  the  lochia  long  before  the  time  at  which  they  usually 
disappear  is  an  unfortunate  symptom  only  when  it  seems  to  be  connected 
with  the  development  of  a  serious  inflammatory  affection,  or  when  it  is  re- 
placed by  a  supplemental  hemorrhage.  It  then  merits  the  closest  attention 
of  the  physician  ;  but  when  the  contrary  is  the  case,  there  is  no  occasion  for 
uneasiness,  since  it  is  the  evidence  of  a  rapid  and  forcible  contraction  of  the 
uterus,  which  is  a  favorable  circumstance. 

§  3.  Of  the  Milk  Fever. 

One  of  the  most  important  phenomena  appertaining  to  the  lying-in  state, 
is  that  usually  designated  under  the  name  of  the  milk  fever.  It  has  already 
been  seen,  when  studying  the  modifications  impressed  on  the  whole  organism 
by  gestation,  that  the  breasts  in  most  women,  even  in  the  very  commence- 
ment of  their  pregnancy,  are  apt  to  become  tumefied,  that  the  swelling  per- 
sists, and  that  sometimes  they  become  the  seat  of  an  abundant  secretion  long 
before  delivery.  After  the  delivery,  they  yield  on  suction  a  liquid  of  a 
yellowish  color,  and  somewhat  more  consistent  than  the  preceding,  which  in 
some  women  escapes  during  the  latter  months  of  gestation.  This  fluid  has 
a  sweetish  taste,  and  is  called  the  colostrum.  It  retains  these  qualities  for 
twenty-four  hours;  but  becomes  whiter  after  that  period.  In  the  course  of 
forty  to  sixty  hours,  the  breasts  enlarge  greatly;  the  subcutaneous  wins, 
seen  through  the  skin,  are  more  swollen  than  during  the  pregnant  state,  and 
the  former  become  manifestly  harder.  The  secretion  of  milk  in  healthy 
women  is  not  usually  attended  with  fever,  the  diminution  of  the  pulse  hardly 
being  prevented  by  it  (see  page  422.)  Still,  if  the  swelling  of  the  breasts  be 
considerable,  headache  may  occur,  as  also,  at  times,  though  more  rarely, 


I'.i;  LABOR. 

slight  si  live  riii  us,  <>r  heal  and  dryness  of  the  skin,  which  is  succeeded  in  a 
few  hours  by  a  copious  perspiration;  there  are  thirst  and  hiss  of  appetite; 
the  tongue  is  slightly  furred ;  the  pulse,  at  first  small  and  contracted,  soon 
becomes  full,  soft,  and  accelerated;  and  the  face  is  flushed  and  animated. 
M.  Pajot  maintains  that  the  pulse  rarely  rises  above  100,  which  is  generally 
true,  though  there  are  exceptions  due  to  individual  susceptibility.  M 
Behier  has  noted  the  pulse  at  130  in  a  case  in  which  everything  went  on 
very  favorably.  During  this  febrile  movement,  which  is  generally  slight, 
the  enlargement  of  the  mamma?  continually  increases,  extends  as  far  as  the 
armpits,  and  involves  the  surrounding  cellular  tissue,  whence  the  patient 
can  no  longer  bring  the  arms  down  alongside  pf  her  body,  and  therefore  hag 
to  hold  them  off.  The  skin  is  sometimes  so  stretched  as  to  become  painful 
and  incommode  the  inspiratory  movements  of  the  chest;  and  lastly,  as  else- 
where stated,  the  discharge  of  the  lochia  either  disappears  altogether,  or  else 
is  greatly  diminished.  This  fever  lasts  for  twelve,  twenty-four,  thirty-six, 
or  possibly  forty-eight  hours,  and  then  is  followed  by  a  calm  ;  at  times, 
however,  it  is  continued  for  three  or  four  days ;  but  in  such  cases  it  is  often 
due  to  a  deep-seated  inflammation,  or  else  soon  exhibits  a  well-marked  in- 
termittence,  and  may  degenerate  into  a  true  intermittent  fever,  which  yields 
readily  to  sulphate  of  quinine.  The  pulse  is  ordinarily  not  very  rapid,  and 
whenever  it  exceeds  100  per  minute,  the  cause  should  be  sought  elsewhere 
than  in  the  lacteal  secretion. 

Authors  have  stated  that  the  milk  fever  is  less  intense  with  primiparse 
than  with  others.  The  same  is  the  case  with  those  who  begin  to  suckle 
their  children  very  soon  after  delivery;  indeed,  it  is  not  at  all  uncommon 
for  the  latter  to  escape  it  entirely.  Finally,  certain  females,  even  of  those 
who  do  not  nurse  at  all,  have  no  milk  fever  whatever,  and  this  notwith- 
standing that  the  breasts  are  considerably  swollen  and  the  secretion  of  milk 
is  abundant.  This  is  a  much  more  common  occurrence  than  is  generally 
supposed,  and  I  have  frequently  had  occasion  to  point  it  out  to  students. 
Still,  I  am  far  from  supposing,  as  some  do,  that  it  forms  the  rule,  and  from 
regarding  every  febrile  movement  occurring  in  a  lying-in  woman,  even 
when  the  lacteal  secretion  is  commencing,  as  indicative  of  an  apparent  or 
concealed  inflammation.  Nothing,  indeed,  could  be  more  reasonable  than 
to  regard  the  swelling  and  painfulness  of  the  mammary  glands  as  the  cause 
of  the  general  reaction  which  usually  accompanies  them,  and  which  dimin- 
ishes or  ceases,  as  soon  as  the  breasts  become  soft,  or  the  system  habituated 
to  the  Dew  condition  of  things. 

In  some  women  the  breasts  remain  inactive,  and  no  milk  it  secreted  ;  it 
really  would  seem,  as  Prof.  P.  Dubois  has  remarked,  that  nature  has  left 
her  work  unfinished  in  them  ;  that,  being  capable  of  becoming  mothers,  and 
able  daring  the  whole  term  of  gestation  to  furnish  the  necessary  materials 
for  the  child's  nutrition,  vet  their  organization  is  absolutely  inadequate  to 
supply  its  wants  after  birth.  I  have  at  this  moment  under  observation  a 
young  priiniparous  woman,  convalescing,  it  is  true,  from  an  attack  of  vario- 
loid which  came  on  immediately  after  delivery,  who  has  not  had  a  single 
drop  of  milk. 

The  milk  fever  generally  manifests  itself  about  forty-eight  hours  subse- 


PHENOMENA    APPERTAINING    TO    THE    LYING-IN    STATE. 


437 


quenttothe  delivery;  at  times  a  little  sooner,  at  others  somewhat  later; 
thus  I  have  seen  two  patients  at  the  Clinique  (and  all  observers  record 
similar  facts),  who  had  this  fever,  the  one  on  the  fifth  and  the  other  on  the 
sixth  day;  and  since  that  time  I  have  often  had  occasion  to  make  the 
same  remark. 

I  For  the  sake  of  greater  precision,  we  think  it  best  to  quote  M.  Better's  ob- 
servations on  the  subject.  "  I  investigated,"  says  this  professor"  the  cases  of  9, 4 
women,  in  order  to  determine  the  precise  period  at  which  the  flow  of  milk  takes 
.lace  In  22  it  occurred  within  the  first  day  after  delivery;  in  170  on  the  second 
day  •  'in  347  on  the  third  day  ;  in  2GG  on  the  fourth  day  ;  in  100  on  the  fifth  day : 
in  22  on  the  sixth  day  ;  in  5  on  the  seventh  day;  in  4  on  the  eighth  day  ;  and  in  I 
not  until  the  eleventh  day."] 

Where  the  child's  death  takes  place  at  an  advanced  stage  of  gestation,  and 
the  dead  body  is  not  expelled  for  several  days  afterwards,  it  is  by  no  means 
uncommon  to  find  all  the  phenomena  of  milk  fever  manifesting  themselves 
In  ordinary  cases,  by  the  time  the  fever  is  over,  the  breasts  have  acquired 
their  highest  degree  of  distention,  and  the  secretion  of  milk  is  very  abundant 
If  the  child  draws  well,  they  are  emptied  and  the  patient  relieved ;  but  should 
the  mother  not  suckle  her  infant,  the  engorgement  continues  for  a  longer 
period,  though  it  wears  away  the  more  promptly  as  it  was  less  considerable 
in  the  first  place,  or  as  the  milk  flows  more  easily  from  the  nipple,  and  as 
the  perspiration  and  lochia  are  the  more  abundant. 

The  question  as  to  the  cause  of  milk  fever  has  been  discussed  again  and 
again-  but  without  entering  into  all  the  arguments  which  this  point  of  doc- 
trine has  given  rise  to,  we  will  merely  remark,  that  the  febrile  movement 
(which,  however,  is  not  always  constant)  most  probably  is  a  consequence  of 
the  oreater  activity  the  mammae  then  assume,  and  that  it  is  nothing  more 
than  what  takes  place  whenever  any  organ  undergoes  a  very  considerable 
and  rapid  development. 

To  women  who  do  not  nurse,  the  lacteal  secretion  may  be  the  cause  ot 
accidents  which  are  to  be  prevented  or  opposed.     Everything  that  could 
tend  to  increase  the  secretion  of  milk,  such  as  succulent  food,  and  the  prac- 
tice of  drinking  freely,  should  be  strictly  avoided.     Warm  and  soft  towels 
should  be  applied  to  the  breasts,  and  renewed  as  soon  as  they  become  moist. 
A  still  better  application  is  cotton  wadding.     By  these  means  perspiration 
is  excited    and  the  heat  of  the  parts  maintained.     Should   the  secretion 
diminish  gradually,  everything  maybe  left  to  nature,  but  should  the  breasts 
become  too  much  swollen,  the  discharge  from  the  nipple  should  be  facilitated 
by  the  use  of  emollient  cataplasms,  or  efforts  be  made  to  empty  them   by 
suction.     In  case  of  these  measures  proving  ineffectual,  recourse  must  be  had 
to  lotions  containing  laudanum  for  the  purpose  of  relieving  pain,  and  to 
sudorifics  and  purgatives  as  revulsives.     As  amongst  the  most  commonly 
employed  diaphoretics,  we  may  mention  weak  tea,  and  the  infusions  of  Pari©- 
taria  and   Borage.     The  purgatives   are  those  which   have,    been   already 
mentioned.     Of  all  the  preparations  which  have  been  extolled  as  lactifuge, 
the  petlt-lait  of  Weiss1  is,  according  to  Desormeaux,  the  only  one  which  is 
.  The  petU-laU  (whey)  of  Weiss  is  prepared  by  infusing  in  boiling  whey  a  Bpecies  of 
galium,  flowers  of  elder,  hypericum,  and  of  the  linden-tree,  together  with  senna  and 
sulphate  of  soda.     It  acts  as  a  purgative.— Translator. 


438  LABOR. 

ptill  employed.  The  same  author  states  that  he  knew  a  lady  to  apply  ac 
ammoniacal  liniment  with  success.  Neuter  asserts,  as  proved  by  experiment, 
that  the  application  of  cups  to  the  back  diminishes  the  flow  of  milk  ;  and 
Van-Swieten  knew  a  galactorrhea  to  yield  to  a  strong  infusion  of  sage, 
taken  in  doses  of  from  one  to  two  ounces  every  three  hours. 

[M.  Blot  was  the  first  to  discover  the  presence  of  sugar  in  the  urine  of  lying-in 
women  as  a  phenomenon  connected  with  lactation.  It  would  seem  from  his  re- 
searchea  that  sugar,  whose  presence  in  urine  had  been  regarded  as  pathognomonic 
of  diabetes,  exists  not  only  in  the  urine  of  all  lying-in  women  but  in  all  nurses, 
and  in  a  certain  proportion  of  pregnant  females.  The  term  Physiological  glycosuria 
has  been  used  to  express  this  fact. 

"In  all  puerperal  women  (45  in  50),"  says  M.  Blot,  "the  sugar  begins  to  appear 
in  the  urine  in  determinate  quantity  coincident  with  the  beginning  of  the  flow  of 
milk;  and  in  many  cases  it  does  not  exist  until  then.  In  a  few  cases  it  may  be 
found  previously,  but  generally  in  very  small  amount.  If  the  secretion  of  milk 
continues,  sugar  continues  to  be  passed  in  the  urine  with  diurnal  variations  as  yet 
unexplained.  When  the  flow  of  milk  is  profuse,  the  proportion  of  sugar  is  usually 
large ;  if  the  former  be  moderate,  the  latter  is  small.  In  this  way  an  examination 
of  the  urine  may  enable  us  to  judge  up  to  a  certain  point  of  the  value  of  a  nurse. 
If  the  fl>i\v  of  milk  be  lessened  or  arrested  from  any  cause,  and  especially  by  the 
development  of  a  more  or  less  serious  morbid  condition,  the  sugar  diminishes  in 
quantity  or  disappears  entirely.  If  health  be  restored  and  the  secretion  re-estab- 
lished the  sugar  reappears.  Finally,  the  urine  contains  sugar  as  long  as  milk 
continues  to  be  secreted  :  I  have  found  it  in  considerable  proportion  (8  grammes  to 
1000  of  urine)  in  one  case  in  which  the  woman  had  been  nursing  for  twenty-two 
months.  In  fact,  the  urine  is  generally  rich  in  sugar  in  proportion  as  the  health 
improves  and  approaches  must  nearly  to  the  normal  or  physiological  condition. 

"  When  lactation  ceases,  the  sugar  disappears,  and  that  at  periods  varying  in 
different  individuals;  earlier  in  those  who  do  not  nurse,  and  later  in  those  who, 
having  nursed,  begin  to  wean  the  child. 

"  Sugar  was  found  in  one- half  the  observed  cases  of  pregnancy.  I  think,  with- 
out being  able  to  affirm  it  positively,  that  this  peculiarity  is  most  likely  to  be 
observed  when  the  breasts  sympathize  most  with  the  pregnant  condition  ;  that  on 
the  contrary,  it  is  absent  when  the  breasts  remain  indifferent,  as  it  were,  to  what  is 
going  on  in  the  uterus."     (Blot.) 

This  physiological  glycosuria  is  also  present  in  the  different  species  of  mammalia. 

As  a  test  of  the  presence  of  sugar  in  the  urine,  M.  Blot  used  successively  Fehling's 
tlu<id.  caustic  potash,  fermentation,  and  the  polarimeter. 

Physiological  glycosuria  seemed  then  to  be  an  established  fact,  when  M.  Leconte 
appeared  with  an  absolute  denial  of  the  presence  of  sugar  in  the  urine  of  nursing 
women,  ami  asserting  that  the  whole  was  a  mistake  due  to  the  presence  of  uric 
acid,  which  gives  reactions  similar  to  those  produced  by  sugar. 

In  this  scientific  dispute  M.  Rruecke  espoused  the  cause  of  M.  Blot,  and,  I  would 
add.  that  a  personal  repetition  of  the  experiments  convinces  me  of  the  existence  of 
physiological  glycosuria.  Further  observations  are,  however,  required  in  order  to  clear 
the  subject  of  ill  doubt.] 


ATTENTIONS    TO   THE    LYING-IN    WOMAN.  439 


CHAPTER    X. 

OP    THE    NECESSARY   ATTENTIONS    TO   THE    LYING-IN    WOMAN. 

The  patient  should  be  placed  in  a  large,  well-aired  chamber,  which  is 
moderately  warm,  and  free  from  all  strong  odors.  In  s  iramer,  the  door? 
and  windows  are  to  be  opened  every  day ;  though,  while  the  air  of  the  apart- 
ment is  being  changed,  sh,e  ought  to  be  carefully  covered,  and  have  the  cur- 
tains drawn,  so  as  to  protect  her  from  any  draft;  but,  at  other  times,  the 
curtains  need  not  be  closed.  The  room  ought  to  be  kept  scrupulously  neat, 
and  the  urine,  excrements,  and  soiled  linen  should  be  removed  at  once. 
The  genital  parts  must  be  often  bathed  with  lukewarm  water,  or  some  emol- 
lient decoction.  These  frequent  ablutions  have  the  further  advantage  of 
calming  any  inflammation  in  the  parts  that  have  been  contused  during  the 
labor ;  they  should  be  made  morning  and  evening,  and  without  uncovering 
the  patient. 

[As  the  newjy  delivered  female  is  liable  to  various  accidents,  and  diseases  which 
make  rapid  progress,  she  ought  to  be  visited  every  day. 

In  the  first  place,  the  physician  should  inquire  into  the  general  condition  and 
determine  the  acceleration  or  lessened  frequency  of  the  pulse,  which  will  rarely 
deceive  as  regards  the  prognosis.  (See  page  422.)  He  will  also  ascertain  carefully 
the  condition  of  the  uterus  as  to  size  (see  page  423)  and  sensibility,  the  character 
of  the  lochia,  and  the  severity  of  the  after-pains.  The  tur'gescence  of  the  breasts 
and  their  secretion  will  also  demand  his  attention  ;  and,  finally,  he  will  inquire 
into  the  state  of  the  bladder  and  rectum.] 

The  secretion  and  excretion  of  urine  generally  present  nothing  abnormal, 
though  there  is  sometimes  difficulty  in  the  emission,  due  to  swelling  of  the 
meatus.  Occasionally,  also,  the  bladder  suffers  temporary  paralysis  from 
severe  pressure  in  tedious  labors.  In  such  cases  the  catheter  should  be  used. 
The  physician  ought  always,  during  the  first  two  or  three  days,  to  inquire 
whether  the  water  passes  freely  and  with  ease,  because  its  collection  in  a 
half-paralyzed  and  benumbed  bladder  may  often  explain  a  state  of  uneasi- 
ness or  suffering  not  otherwise  to  be  accounted  for. 

[Retention  of  urine  sometimes  occurs  with  lying-in  women  immediately  after 
delivery,  and  sometimes  not  until  after  several  days.  In  the  former  case,  it  would 
seem  due  to  paralysis  of  the  bladder  or  contusion  of  its  neck;  in  the  latter,  it  is 
probably  caused  by  consecutive  inflammation.  At  other  times  the  patients  do  not 
empty  the  bladder,  and  it  remains  considerably  distended  without  their  knowing 
it.  Therefore,  after  questioning  the  patient  on  this  subject,  the  accoucheur  ought 
himself  to  ascertain  whetner  the  bladder  is  emptied.  It  is  very  important  not  to 
overlook  a  distended  bladder,  though  it  is  often  done,  for  then  the  physician  neces- 
sarily falls  into  an  error  of  diagnosis  in  regard  to  the  cause  of  the  suffering  in  the 
lower  part  of  the  abdomen. 

The  symptoms  of  retention  of  urine  in  lying-in  women  have  some  peculiarities. 
The  bladder,  being  pressed  forward  by  the  uterus,  which  forms  a  resisting  plane 
behind  it,  almost  always  projects  sufficiently  above  the  pubis  to  form  a  tumor  there 
which  is  appreciable  to  the  eye.  The  tumor  is  rounded,  soft  and  supple  to  the 
touch,  fluctuating,  ami  dull  on  percussion.  All  these  characters  have  but  a  sec- 
ondary value,  so  that  whenever   retention  of   urine  is  suspected,  the   uterus  should 


-}■!<>  LABOR. 

first  be  sought  for,  and  will  be  known  by  its  size  and  especially  by  its  hardness" 
if  the  uterus  cannot  be  felt,  it  is  because  it  is  concealed  by  the  distended  bladder. 
Repletion  of  the  bladder  has,  also,  upon  the  position  of  the  womb  an  effect  which 
should  be  'well  understood  :  when  the  distended  organ  rises  into  the  lower  part  of 
the  abdomen,  it  carries  with  it  the  uterus,  whose  fundus  is  then  found  as  high  as, 
and  often  even  above,  the  umbilicus,  and  when  the  catheter  is  used,  it  descends  as 
the  water  flows.  Whenever,  therefore,  the  fundus  of  the  uterus  is  found  too  high 
up,  the  sub-pubic  region  should  be  examined  carefully  to  ascertain  whether  the 
bladder  projects  there.  If  the  latter  be  empty,  the  fingers  will,  without  tfiineulty, 
feel  the  anterior  surface  of  the  womb  throughout. 

Retention  of  urine  sometimes  continues  in  these  cases  for  several  days,  and  even 
for  several  weeks.  So  long  as  it  lasts,  the  catheter  should  be  used  at  least  twice 
a  day  according  to  the  rules  already  pointed  out  (see  page  61).  The  bladder 
almost  always  recovers  its  power  after  a  certain  time,  so  that  there  is  no  occasion 
for  alarm  should  the  retention  last  for  several  days.] 

The  constipation  that  is  so  common  during  the  last  stages  of  gestation, 
oftentimes  still  persists  after  the  delivery  for  four,  six,  or  even  eight  days  ; 
and  this  prolonged  retention  of  the  fecal  matters  may  give  rise  to  anxiety, 
headache,  loss  of  sleep,  and  sometimes  even  to  a  feeling  of  weight,  or  actual 
pain  in  one  of  the  iliac  fossae;  all  which  symptoms  disappear  like  magic 
upon  the  administration  of  some  mild  laxative.  Where  the  costiveness 
continues,  a  state  of  suffering  very  frequently  results,  which  may  occasion  a 
blight  febrile  movement;  and  the  frequency  of  pulse,  thus  produced,  coin- 
ciding with  the  pain  caused  by  an  unusual  retention  of  the  fecal  matters, 
which  pain  is  most  commonly  located  in  some  part  of  the  hypogastric 
region,  and  is  augmented  by  pressure,  may  give  rise  to  suspicions  of  a  peri- 
toneal inflammation  that  really  does  not  exist ;  and  I  have  known  this  error 
to  be  committed  where  the  pain  and  fever  that  had  resisted  the  application 
of  leeches,  rapidly  disappeared  after  the  exhibition  of  a  purgative.  The 
retention  of  the  faeces  may  also  result  from  a  paralysis  of  the  rectum,  which 
paralysis  itself  is  a  consequence  of  the  pressure  made  upon  it  by  the  head 
during  its  prolonged  sojourn  in  the  excavation.  I  have  known,  says  M. 
Martin,  of  Lyons,  the  faeces  to  be  retained  more  than  twenty  days  after  a 
laborious  delivery,  and  to  accumulate  in  such  large  quantities,  and  acquire 
such  a  firm  consistence  as  to  equal  the  size  of  a  child's  head  at  term  ;  and 
as  all  the  usual  laxatives  failed,  I  was  obliged  to  introduce  a  scoop,  and 
bring  the  hardened  matters  away  piecemeal ;  but  even  then  the  gut  did  not 
at  once  regain  its  functions,  though  a  fresh  accumulation  was  prevented  by 
the  use  of  irritant  injections,  and  the  contractility  of  the  intestine  was  not 
perfectly  re-established  until  twenty-nine  days  afterwards,  at  which  period 
the  patient  left  the  hospital.     (Comptes  Rtndus,  p.  32.) 

A  temporary  constipation,  prior  to  the  invasion  of  the  milk  fever,  is  a 
matter  of  no  consequence;  but  should  it  persist  for  several  days  afterwards, 
injections  may  be  administered,  either  simple,  or  else  rendered  slightly  lax- 
ative by  the  addition  of  an  ounce  or  an  ounce  and  a  half  of  the  vxiel  mercu- 
r't'de,  or  a  decoction  of  senna  Leaves  ;  and  where  these  measures  do  not 
answer,  a  mild  purgathe,  such  as  the  following,  is  exhibited  by  the  mouth, 
viz.,  from  half  an  ounce  to  an  ounce  of  castor  oil,  rubbed  up  witn  an  ounce 
of  almond  emulsion  and  a  little  lemon  syrup.   The  compound  licorice  powder 


ATTENTIONS    TO    THE    LYING-IN    WOMAN.  44] 

of  the  pharmacopoeia  is  a  very  efficient  and  pleasant  laxative,  and,  although 
recommended  especially  for  the  constipation  of  pregnancy,  will  be  found  to  an- 
swer the  same  indications  after  labor.  Many  patients  suffer  from  hem<  >rrh<  >ids 
during  convalescence,  and  in  these  cases  half-grain  doses  of  aloes,  administered 
night  and  morning,  have  been  recommended  by  Fordyce  Barker  as  a  specific. 

The  woman  should  make  no  exertion  during  the  first  few  days,  and  if  the 
labor  has  been  long  and  painful,  or  attended  with  any  serious  accident,  it 
is  best  that  she  should  be  protected  from  violent  and  rude  motions,  and  that 
the  bed  be  not  made  up  until  after  the  milk  fever  has  subsided.  When, 
however,  the  patients  are  but  slightly  fatigued,  the  bed  may  be  made  on  the 
evening  of  the  day  preceding  that  on  which  the  milk  fever  supervenes,  after 
which  it  should  be  left  until  the  next  day  but  one ;  thereafter  it  may  be 
made  every  day.  The  woman  should,  on  these  occasions,  be  transferred  to 
another  couch. 

It  is  very  important  that  the  patient  should  not  rise  before  the  ninth  day, 
which  is  a  favorite  time  for  getting  up  with  the  working  classes,  and  where 
she  is  in  easy  circumstances,  and  can,  without  detriment  to  her  interests, 
abstain  for  a  longer  period  from  her  household  duties,  she  should  be  required 
to  remain  in  bed  for  at  least  two  weeks.  It  were  better  not  to  adopt  arbitrarily 
any  particular  day,  but  to  regulate  the  conduct  to  be  followed  by  the  degree  of 
atrophy  of  the  uterus.  When  the  latter  has  lost  the  greater  part  of  its  bulk, 
and  its  fundus  descends  and  disappears  in  the  lesser  pelvis,  the  patient  may 
get  up.  One  woman  may  do  so  without  danger  on  the  eighth  day,  whilst 
another  ought  to  remain  in  bed  after  the  fifteenth  day.  At  this  period  she 
may  be  carried  to  an  easy-chair,  where  she  will  remain  seated  for  an  hour 
or  two,  and  again,  on  the  following  day,  for  two  or  three  hours.  On  the 
third,  she  might  try  her  strength  by  taking  a  few  turns  around  the  chamber, 
and  then  through  the  apartments ;  but  it  would  be  imprudent  to  venture 
out  of  doors,  especially  in  the  winter  season,  before  the  fifteenth  or  twentieth 
day,  and  only  then  in  fine  weather  and  about  the  middle  of  the  day. 

Most  women,  actuated  by  a  religious  feeling,  go  to  church  on  the  occasion 
of  their  first  going  out ;  and  as  these  buildings  are  always  cold  and  damp, 
they  often  return  with  the  germs  of  an  inflammatory  disease,  which  sooner 
or  later  develops  itself;  and  hence  the  physician  should  advise  the  deferring 
of  this  religious  ceremony,  called  the  churching,  to  a  more  distant  period. 

As  regards  her  diet,  the  articles  ought  to  be  of  the  mildest  character,  and 
of  easy  digestion  ;  thus,  as  a  general  rule,  she  will  only  need,  during  the  first 
day  or  two,  a  little  porridge  two  or  three  times  in  the  course  of  the  day,  and 
Borne  broth  during  the  night ;  and  she  should  observe  an  absolute  diet  pend- 
ing the  duration  of  the  milk  fever,  for  fear  of  adding  to  its  intensity  ;  though 
even  here,  if  the  general  reaction  is  moderate,  she  might  be  allowed  some 
broth.  After  the  fever  is  over,  the  quantity  of  nourishment  is  gradually 
augmented ;  so  that,  by  the  twelfth  or  the  fifteenth  day,  the  woman  has 
resumed  her  ordinary  habits.  In  those  who  do  not  nurse,  the  regimen  must 
be  more  restricted,  especially  when  the  breasts  still  remain  engorged  or 
painful. 

[The  regimen  of  lying-in  women,  as  jusl  indicated,  was  rigorously  observed  until 
within  :t  lew  years;   but,  we  ought  to  add,  there  is  now  a  strong  disposition  to  act 


442  LABOR. 

differently.  Legroux,  physician  at  the  Hotel  Dieu,  introduced  the  innovation  by 
showing  that  not  only  was  there  no  danger,  but  often  a  real  advantage  in  giving 
nourishment  freely  to  newly  delivered  patients.  Accordingly,  he  allows  soups  to 
the  women  in  his  wards  on  the  first  day,  and  solid  food  on  the  second  day  after 
delivery.  I  have  followed  his  example  for  several  years,  and  have  had  no  reason 
to  be  other  than  pleased  with  it.  Immediately  after  delivery,  therefore,  I  allow 
soup,  taken  in  small  quantities,  but  freely.  On  the  next  day  solid  food  is  per- 
mitted; an  egg  or  mutton  chop,  for  example,  with  bread  and  claret  and  water. 
After  the  secretion  of  milk  has  begun,  the  patients  can  resume  their  usual  diet. 
This  plan  has  but  the  single  inconvenience  of  eliciting  the  disapproval  of  those  whe 
have  grown  up  in  other  ways  of  doing;  but  inasmuch  as  it  is  better  for  the  patients, 
we  shall  have  to  disregard  these  objections.] 

Throughout  the  whole  lying-in  period,  the  patient  should  use  some  diluted 
ptisan,  moderately  sweetened  and  rendered  aromatic,  as  an  ordinary  drink  ; 
such  as  a  solution  of  gum,  or  an  infusion  of  mallows,  of  violets  or  linden, 
the  orange  or  chamomile  flowers,  &c,  etc. ;  but  acidulated  drinks  must  never 
be  allowed  to  those  who  nurse.  About  the  seventh  or  eighth  day,  most 
patients  ask  their  medical  attendant  for  something  to  drive  away  the  milk, 
which,  of  course,  is  generally  a  useless  precaution ;  but,  perhaps,  it  would 
be  better  to  yield  to  a  very  popular  prejudice,  so  as  to  escape  all  subsequent 
reproach.  The  Canne  de  Provence,  and  the  infusion  of  periwinkle,  &c, 
enjoy  a  high  reputation  for  this  purpose ;  and  as  the  root  of  the  former  is 
nearly  inert,  it  will,  on  that  account,  be  preferably  employed. 

Most  women  think  it  necessary  to  be  purged  towards  the  end  of  their 
lying-in  ;  and  though,  when  the  physician  discovers  any  positive  counter- 
indication  to  the  administration  of  even  a  mild  purgative,  he  doubtless  should 
not  yield  to  their  desires ;  yet,  under  ordinary  circumstances,  he  ought  to 
purge  them  slightly,  both  on  account  of  his  own  reputation  and  to  avoid 
subsequent  unjust  reproaches;  indeed,  this  will  become  necessary,  if  the 
tongue  is  broad,  furred,  and  yellowish  or  greenish,  the  mouth  bitter  and 
clammy,  and  there  is  a  loss  of  appetite.  The  Seidlitz  waters  and  castor-oil 
are  perhaps  preferable,  from  their  mildness  and  certainty  of  operation. 

The  excitability  of  the  nervous  system  is  such,  in  lying-in  women,  that 
the  greatest  care  should  be  exercised  in  keeping  away  everything  that  might 
excite  them,  and  in  avoiding  all  acute  moral  emotions. 


PART    IV. 

PATHOLOGY  OF  PREGNANCY. 

THE  pathology  of  pregnancy  comprises  all  functional  derangements 
occurring  in  pregnant  women,  as  well  as  all  spontaneous  or  accidental 
lesions  of  the  ovum  which  may  compromise  the  health  or  life  of  the  foetus. 
As  the  latter  class  usually  either  escape  detection,  or  are  not  discovered 
until  it  is  too  late  to  remedy  them,  they  will  be  considered  briefly ;  all,  in 
fact,  that  can  be  said  of  them  is  limited  to  certain  questions  of  pathological 
anatomy,  foreign  to  the  main  object  of  this  work. 

[Some  of  the  numerous  diseases  observed  during  pregnancy  are  the  result  of  this 
condition  ;  others  occur,  as  it  were,  by  chance,  and  often  happen  under  other  cir- 
cumstances. On  this  account,  they  are  treated  of  in  separate  chapters  ;  a  division, 
however,  which  is  far  from  perfect,  as  the  distinction  between  the  two  classes  can- 
not always  be  defined.  The  first  chapter  is  devoted  to  the  diseases  which  may 
occur  during  pregnancy,  and  the  second  to  those  which  are  the  result  of  it.  After- 
ward are  described  extra-uterine  pregnancies,  lesions  of  the  ovum  and  of  the  pla- 
centa, and  diseases  of  the  foetus  and  its  death.    The  last  chapter  treats  of  abortion.] 


CHAPTER  I. 

OF  THE  DISEASES  WHICH  MAY  EXIST  DURING  PREGNANCY,  AND  OF 
THE  RECIPROCAL  INFLUENCE  WHICH  THEY  MAY  HAVE  UPON 
THEIR   PROGRESS    AND    TERMINATION. 

Though,  says  Antoine  Petit,  pregnancy  exposes  women  to  various  disorders, 
it  also  protects  them  from  many  very  dangerous  diseases,  arrests  the  pro- 
gress of  others,  and  sometimes  even  cures  those  with  which  they  were  pre- 
viously affected.  This  proposition,  though  asserted  almost  as  a  maxim  by 
the  author  quoted,  is,  unfortunately,  far  from  being  strictly  true.  Antoine 
Petit  was  indeed  strangely  deceived  in  his  appreciation  of  the  influence  of 
pregnancy  upon  acute  diseases  existing  before  it  or  occurring  during  its 
progress;  still,  as  many  physicians  partake  of  his  error,  we  have  thought  it 
right  to  notice  it  at  the  outset. 

§  1.  Epidemic  Diseases. 

1.  Influenza. — Though  some  epidemics  have  appeared  to  spare  pregnant 
women,  many  have  affected  them  as  severely,  at  least,  as  other  individuals 
exposed  to  the  same  influences.     Thus  I  found,  as  did  also  M.  Jacquemier, 

4  13 


444  PATHOLOGY    OF   PREGNANCY. 

at  the  Maternity  Hospital,  thai  the  epidemic  of  influenza  attacked  a  great 
many  pregnant  women  ;  but,  contrary  to  his  observation,  I  witnessed  numer- 
ous abortions  as  a  consequence  either  of  the  disease  itself,  or  of  the  violent 
spells  of  coughing  which  tormented  the  patients. 

2.  Cholera. — The  severe  epidemics  of  cholera  which,  in  1832  and  1849. 
were  so  fatal  in  the  capital,  did  not  span'  pregnant  women ;  and  we  had  the 
pain  of  witnessing  the  death  of  quite  a  number. 

Dr.  Bouchut  has  endeavored,  in  a  quite  recent  work,  to  appreciate  the 
effect  of  pregnancy  upon  cholera,  and  vice  versa.  Relying  upon  52  obser- 
vations, he  commences  by  showing  that  pregnancy  has  no  influence  upon 
the  invasion  of  cholera,  that  it  protects  from  it  no  more  than  it  predisposes 
to  it,  and  that  when  the  disease  appears,  it  does  so  without  any  modification, 
in  all  its  forms  and  severity. 

Cholera  has,  however,  an  incontestable  influence  upon  the  course  of  gesta- 
tion, often  shortening  its  duration.  Thus,  25  women  out  of  52  aborted  in 
consequence  of  the  disease,  and  the  same  would  probably  have  been  the 
case  with  others,  had  not  the  patients  been  removed  by  an  early  death. 
Except  in  some  rare  instances,  abortion  took  place  only  in  cases  in  which 
the  disease  lasted  over  twenty-four  hours. 

Of  the  25  women  who  aborted,  16  recovered  ;  12  had  the  disease  with 
moderate  severity,  though  lasting  for  a  considerable  time;  the  attack  in  4 
was  dangerous  and  rapid,  and  9  died. 

The  observations  of  M.  Bouchut  have  elicited  the  remarkable  fact  that 
abortion  is  very  common  in  cholera  patients  after  the  fifth  month  of  preg- 
nancy, but  very  rare  at  its  commencement.  Thus,  of  the  16  women  who 
aborted  and  recovered,  only  1  was  three  months  pregnant,  1  four,  6  five, 
and  1  six ;  and  the  least  advanced  of  the  9  who  died  after  abortion,  had 
reached  four  months  and  a  half. 

Of  the  27  women  who  did  not  miscarry,  only  six  recovered  and  had  their 
pregnancies  to  continue.  The  attacks  which  they  suffered  were  of  medium 
severity,  and  of  several  days'  duration  :  21  died  with  the  disease  in  a  dan- 
gerous and  rapid  form. 

Altogether  there  were  30  deaths  out  of  52  cases.  We  see,  therefore,  that 
the  prognosis  of  cholera  is  not  rendered  more  favorable  by  the  state  of 
pregnancy. 

We  have  said  that  6  of  the  patients  recovered,  and  had  their  pregnancies 
to  pursue  their  regular  course.  Others,  who  had  reached  a  more  advanced 
stage,  were  delivered  prematurely  of  living  children.  From  this,  it  plainly 
results  that  cholera  is  not  always  communicated  to  the  fetus,  and  that 
though  the  latter  usually  succumbs  either  before  its  expulsion,  or  before  the 
mother,  in  those  cases  where  her  early  decease  did  not  allow  the  abortion  to 
take  place,  its  death  cannot  be  attributed  to  a  transmission  of  the  disease. 
Besides,  the  autopsy  of  the  children  revealed  nothing  which  could  be 
regarded  as  pertaining  to  cholera. 

What,  then,  is  the  cause  of  the  death  of  the  fetus,  preceding,  as  it  almost 
always  does,  its  own  expulsion,  or  the  death  of  the  mother? 

M.  Bouchut  thinks  that  it  is  a  consequence  either  of  a  mechanical  com- 
pression of  the  uterus   produced  by  the  cramps  and  convulsions  of  the  ab- 


DISEASES     OCCURRING     DURING     PREGNANCY.  445 

doniinal  muscles,  or  to  the  severe  diet  to  which  the  patients  are  subjected, 
again,  he  supposes  that  it  may  be  occasioned  by  the  profuse  discharges  from 
the  bowels,  which,  by  depriving  the  blood  of  its  serum,  dry  up,  as  it  were, 
the  sources  of  nutrition.  For  my  own  part,  I  regard  asphyxia  as  the  only, 
or  at  least  the  usual,  cause  of  the  death  of  the  foetus.  The  coagulation  of 
the  blood,  and  its  stagnation  in  the  vessels,  are  evidently  calculated  to  sus- 
pend the  utero-placental  circulation ;  and  the  interruption  of  the  latter, 
depriving  the  foetus  as  it  does  of  the  means  of  respiration,  must  necessarily 
lead  to  its  rapid  death. 

M.  Devilliers,  Jr.,  read  before  the  Academy  of  Medicine  an  observation 
tending  to  prove  that  abortion  has  a  favorable  effect  upon  the  termination 
of  cholera,  and  causing  him  to  feel  justified  in  recommending  the  provoca- 
tion of  premature  labor,  as  a  means  of  diminishing  the  danger  of  the  dis- 
ease. In  examining  under  this  point  of  view  the  results  furnished  by  M. 
Bouchut,  a  result  favorable  to  the  opinion  of  M.  Devilliers  is  at  once  dis- 
coverable ;  since  of  the  27  patients  who  did  not  miscarry,  21  died,  whilst  9 
deaths  only  occurred  after  25  abortions.  Still,  it  should  be  observed,  that 
of  the  women  who  recovered  after  aborting,  4  only  had  the  disease  in  a  rapid 
and  dangerous  form  ;  whilst  of  the  21  who  died  undelivered,  the  disease  Was 
very  severe,  and  barely  lasted  a  few  days.  This  early  fatal  termination  was, 
very  probably,  the  only  cause  which  prevented  abortion. 

The  view  of  M.  Devilliers  cannot,  therefore,  be  received  without  new  con- 
firmatory observations. 

In  short,  though  pregnancy  does  not  affect  sensibly  the  progress  and  dan- 
ger of  cholera,  the  latter  leads,  in  the  great  majority  of  cases,  to  the  death 
or  premature  expulsion  of  the  foetus. 

§  2.  Endemic  Diseases. 

Intermittent  Fever. — There  can  be  no  doubt  that,  as  M.  Ebrard  has  en- 
deavored to  prove,  the  grave  disorders  and  deep  perturbations  produced 
throughout  the  economy  by  the  febrile  paroxysms,  the  obstinate  vomitings 
which  attended  many  of  them,  and  the  cough,  diarrhoea,  and  colics,  may 
disturb  greatly  the  functions  of  the  womb ;  also  that  the  fluxion  and  con- 
gestion so  often  produced  by  this  fever,  may  cause  the  premature  expulsion 
of  the  product  of  conception. 

The  possibility  of  the  occurrence  being  incontestable,  the  indication  to 
remove  the  morbid  condition  follows  as  a  matter  of  course.  I  mention  this 
influence  of  intermittent  fever  upon  the  pregnant  condition  only  as  affording 
an  opportunity  of  discarding  completely  the  advice  of  some  persons  who 
recommend  the  rejection  of  sulphate  of  quinine,  as  likely  to  produce  abor- 
tion or  premature  labor.  The  miscarriages  laid  to  the  charge  of  the  sul- 
phate of  quinine  should  certainly  be  attributed  to  the  disease  itself,  and  not 
to  the  remedy.  For  my  own  part,  I  have  had  occasion  to  use  it  six  times 
at  various  periods  of  pregnancy,  in  doses  of  ten,  twelve,  and  even  fifteen 
grains  in  the  twenty-four  hours,  without  having  had  to  repent  of  it.  Many 
practitioners,  who,  like  MM.  Thezet,  Delmaz,  Alamo,  and  Ebrard,  have 
long  practised  in  localities  where  this  fever  is  endeini:,  have  never  been 
obliged  in  complain  of  the  action  of  sulphate  of  quinine  when  administered 


446  PATHOLOGY  OF  PREGNANCY 

during  pregnancy.     Not  only  is  it  an  innocent  remedy,  but  the  surest  pre- 
ventive means  when  abortion  is  imminent  in  consequence  of  the  fever. 

[Some  facts  go  to  prove  that  pregnant  women  attacked  with  intermittent  fever 
may  communicate  the  disease  to  the  foetus.  Dr.  Stokes,  of  Dublin,  states,  that  he 
saw  a  case  of  tertian  ague  during  pregnancy  in  which  the  foetus  was  affected  with 
convulsive  movements  remarkable  for  their  correspondence  with  the  apyretic  days 
if  the  mother. 

M.  Pitre-Aiibanais  relates  two  cases  of  intermittent  fever  communicated  to  the 
foetus  by  the  mother.  Both  of  these  children  were  born  with  hypertrophied  spleens, 
and  their  attacks  of  fever  coincided  both  as  to  day  and  hour  with  those  of  the  mother. 
(Bourgeois  de  Turcoing.) 

M.  Jacquemier  also  says,  that  it  would  seem  that  intermittent  fever  may  attack 
both  mother  and  foetus  at  the  same  time,  and  the  facts  upon  which  he  bases  his 
assertion,  though  few,  appear  conclusive.  Schurig  relates  that  a  woman  had  a 
rebellious  quartan  ague  in  the  second  month  of  her  third  pregnancy,  and  that  in 
the  last  month  either  before  or  after  the  paroxysms  she  felt  the  child  to  be  excited, 
shiver,  and  roll  perceptibly  from  one  side  to  the  other.  At  last,  after  a  severe 
paroxysm,  she  was  delivered  of  a  girl  which  had  a  violent  attack  of  fever  at  the 
same  hour  with  the  mother,  and  which  continued  to  return  during  seven  weeks. 
Similar  cases  were  observed  by  Hoffman  and  Russell.  (Jacquemier,  Tvaitt  d' Ob- 
stetrique.)] 

§  3.  Eruptive  Fevers. 

i.  Variola.  —  The  eruptive  fevers  seem,  generally,  to  be  much  more  dan- 
gerous to  pregnant  women  than  to  other  individuals.  Variola,  especially, 
of  all  these  diseases,  has  the  most  disastrous  influence  upon  the  pregnant 
condition  ;  some  authors,  indeed,  state  that  it  is  almost  uniformly  fatal,  par- 
ticularly when  it  produces  abortion. 

It  is  important,  as  regards  the  prognosis,  to  distinguish  between  the  con- 
fluent and  discrete  forms  of  small-pox.  (Chaigneau.)  The  former,  which 
is  so  fatal,  independent  of  pregnancy,  as  to  destroy  a  third  of  whom  it  at- 
tacks, is  still  more  to  be  dreaded  during  gestation,  sparing,  as  it  does,  almost 
none  of  its  victims ;  the  latter,  on  the  contrary,  is  far  from  always  occasion- 
ing abortion  or  premature  labor,  and  even  where  the  pregnancy  is  ended 
before  term,  the  mother  often  recovers. 

Dr.  Gariel  thinks  that  the  lumbar  pains,  which  are  so  severe  in  the  first 
stage  of  variola,  have  a  great  tendency  to  produce  abortion.  I  have  seen  in 
two  cases  of  the  discrete  form,  slight  contractions  coinciding  with  these  lum- 
bar pains  ;  but  1  was  able  to  arrest  them  by  the  use  of  opiate  injections.  In 
several  other  instances,  I  witnessed  nothing  of  the  kind,  and  I  think  with 
M.  Chaigneau  (Thesis,  1847),  that  abortion  is  specially  liable  to  occur  when 
the  pustules  are  in  full  suppuration,  and  the  secondary  fever  appears,  in 
connection  with  the  grave  symptoms  which  usually  accompany  it. 

To  recapitulate :  confluent  small-pox  nearly  always  occasions  abortion,  and 
this  is  almost  uniformly  followed  by  the  death  of  the  mother :  out  of  23 
abortions  observed  by  M.  Serres  under  these  circumstances,  there  were  22 
deaths.  Discrete  small-pox,  on  the  contrary,  generally  allows  the  pregnancy 
to  continue  its  course,  and  even  when  it  interrupts  its  progress,  the  mother 
usually  recovers,  and  in  the  latter  months  the  child  is  expelled  alive. 

When  the  foetus  is  not  expelled,  it  may  continue  to  grow,  and  often  it  does 


DISEASES    OCCURRING    DURING    PREGNANCY.  447 

not  appear  at  birth  to  have  suffered  much  from  the  disease  which  had  endan- 
gered its  mother's  life  so  greatly ;  in  other  cases,  however,  either  because  it 
receives  the  germ  of  the  disease  which  affects  the  mother,  or  because  the 
deep-seated  disorders  which  the  variola  produces  in  the  maternal  system 
also  exert  an  unfavorable  influence  upon  the  foetal  life,  it  soon  perishes.  In 
the  former  case,  variolous  pustules,  in  every  respect  similar  to  those  on  the 
mother,  may  be  detected  on  the  body  of  the  child. 

[We  have  just  stated  that  the  unborn  child  of  a  mother  affected  with  variola  may 
contract  the  same  disease,  a  fact  attested  by  various  authors.  In  this  case,  the 
mother  communicates  a  contagious  disease  with  which  she  is  herself  suffering ;  but 
it  would  be  wrong  to  suppose  that  every  pregnant  woman  having  variola  must 
necessarily  transmit  it  to  her  child.  M.  Serres  knew  of  twenty-two  non-variolous 
children  born  of  women  who  had  the  disease  during  pregnancy.  Mead  even  holds 
that  if  the  woman  does  not  abort,  her  child  is  exempt  from  variola  for  the  rest  of 
its  life,  provided  it  be  not  born  before  the  maturity  of  the  eruption.  The  fact  is 
curious,  but  denied  by  Contugno,  whose  opinion  may  find  support  in  the  following 
facts  :  Two  pregnant  women  were  inoculated  ;  the  eruption  was  discrete,  and  gesta- 
tion progressed.  At  the  usual  period  they  were  delivered  of  healthy  children, 
which,  at  three  years  of  age,  were  inoculated  and  had  the  regular  disease. 

On  the  other  hand,  it  seems  that  the  foetus  only  may  have  variola  before  birth, 
even  though  the  mother  may  never  have  had  it.  Though  the  fact  may  appear  ex- 
traordinary, it  cannot  be  questioned  in  opposition  to  the  testimony  of  such  credible 
authors  ns  Ebel,  Kesler,  Watron,  Jenner,  Deneux,  Royer,  Bouchut,  and  Chaigneau. 
all  of  whom  have  seen  children  born  with  variola,  the  mothers  being  free  from  the 
disease.  In  several  of  these  cases,  the  mothers  having  been  vaccinated  were  insus- 
ceptible to  the  epidemic  influence,  yet  were  able  to  communicate  the  virus  to  the 
foetus. 

Congenital  variola  appears  at  all  stages  of  pregnancy.  Before  the  third  month 
it  is  rare;  and  generally  it  is  discrete,  so  that  there  may  not  be  at  the  utmost  more 
than  a  hundred  pustules  on  the  entire  body,  and  often  many  less.  It  is  observed 
that  the  pustules  do  not  follow  the  same  course  of  evolution  as  they  do  in  the  open 
air,  but  being  always  bathed  in  the  amniotic  fluid  present  the  same  phenomena  as 
those  which  affect  the  mucous  membranes.  They  are  whitish  and  flattened,  but  larger 
than  such  as  are  found  in  the  cavity  of  the  mouth.  A  few  become  resolved,  but 
others  ulcevate  quickly  when  the  slight  pseudo-membranous  disk  covering  them 
falls  off.  The  wound  suppurates  little,  never  furnishes  crusts  on  account  of  the 
moist  state  of  the  parts,  and  cicatrizes  without  leaving  any  mark.  Occasionally, 
however,  the  characteristic  scar  is  seen,  but  even  then  is  very  superficial. 

When  mother  and  foetus  have  variola  at  the  same  time,  the  pustules  appear 
at  the  same  time  in  both.  M.  Chaigneau  has,  however,  seen  a  few  cases  in  which 
it  was  later  in  the  children,  not  occurring  until  long  after  it  had  disappeared  from 
the  mother.  The  unborn  child  affected  with  variola  is  almost  sun'  to  die.  (Bour- 
geois de  Tourcoinff.] 

2.  Scarlatina,  when  of  some  severity,  acts  in  nearly  the  same  way  as 
variola ;  the  danger,  however,  is  usually  far  less  both  to  mother  and  child. 
It  sometimes  gives  rise  to  abortion,  and  then  the  patients  very  often  succumb. 
My  opinion  coincides  with  that  of  M.  Serres,  who  thinks  that  women  are 
much  more  likely  to  contract  the  disease  when  recently  delivered  than  they 
are  during  pregnancy,  for  I  have  never  seen  scarlatina  during  gestation, 
though  I  have  had  the  misfortune  to  lose  two  newly-delivered  females  from 
the  disease. 


448  PATHOLOGY    OF    PEKGXANCY. 

3.  Measles,  according  to  Levret,  is  quite  as  grave  as  the  preceding.  In 
four  cases,  however,  observed  by  M.  Grisolle,  the  regular  course  of  gestation 
was  undisturbed,  and  two  similar  instances  have  come  under  my  own  notice. 

[Unfortunately,  however,  this  is  not  always  the  ease,  for  M.  Bourgeois  de  Tour- 
coing,  from  whose  excellent  memoir  we  have  made  several  extracts  whilst  prepar- 
ing this  chapter,  has  himself  met  with  fifteen  cases  "|  rubeola  in  pregnant  women, 
eight  of  whom  either  aborted  or  were  delivered  prematurely.  In  the  remainder 
the  pregnancy  was  not  interfered  with.  In  the  former  the  disease  was  most  severe 
in  the  most  advanced  cases,  and  the  first  symptoms  of  abortion  or  delivery  appeared 
toward  the  end  of  the  disease. 

Very  rarelv  have  children  been  born  affected  with  rubeola;  Rosen  and  Vogel 
relate  some  cases  ;  Guersant  met  with  one,  and  Bourgeois  mentions  another,  in 
wdiich  the  child  lived  but  three  days. 

I  4.  Various  Sporadic  Diseases. 

1.  Typhoid  Fever.  —  Typhoid  fever  may  occur  at  any  stage  of  pregnancy.  It  often 
causes  abortion,  which  may  take  place  in  the  first  or  second  week  of  the  disease. 

According  to  Bourgeois,  of  twenty-two  cases  attacked  early  in  pregnancy,  six  who 
had  the  disease  lightly  did  not  abort,  whilst  out  of  sixteen  grave  cases  twelve 
aborted.  Of  fifteen  cases  of  fever  occurring  during  and  after  the  seventh  month, 
the  same  observer  notes  nine  cases  of  premature  delivery.  Of  these,  five  occurred 
during  the  first  week  of  the  disease;  five  of  the  children  were  still  born,  one  lived 
two  days,  and  one  survived. 

The  remaining  women  were  delivered  during  the  second  week  of  the  fever;  two 
of  the  children  died  during  labor;  one  lived  two  days  and  a  half,  and  one  only  was 
raised,  being  an  eight-month's  child.  The  two  surviving  children  presented  nothing 
peculiar.] 

Though  I  have  rarely  had  occasion  to  observe  typhoid  fever  during  preg- 
nancy, I  have  frequently  seen  it  occur  during  the  lying-in.  Its  commence- 
ment is  usually  insidious,  the  first  symptoms  having  always  been  those  of  a 
puerperal  inflammation,  and  presenting  all  the  characters  of  the  typhoid 
disease  only  after  the  lapse  of  the  first  few  days,  and  the  disappearance  of  the 
abdominal  symptoms.  What  is  very  singular,  if  I  may  judge  by  the  cases 
which  I  have  observed,  the  typhoid  fever,  so  far  from  being  influenced  un- 
favorably by  the  puerperal  state,  is  even  less  grave  than  in  the  ordinary 
conditions  of  life.  Not  one  case  of  17,  of  typhoid  fever  supervening  a  few 
days  after  delivery,  proved  fatal.  The  same  remark  is  made  by  M.  Fauvel, 
who  d'nl  not  witness  a  single  death  in  the  cases  of  the  lying-in  women  who 
had  the  disease.  Although  the  cases  are  too  few  to  warrant  a  definite  con- 
clusioB  from  them,  they  seemed  to  me  of  sufficient  interest  to  be  recorded. 

2.  Pneumonia  is,  without  doubt,  of  all  the  acute  inflammations  of  the 
envelopes  or  of  the  parenchyma  of  the  organs,  one  of  the  most  likely  to  pro- 
duce abortion  or  premature  labor.  M.  Grisolle  has  himself  observed  4  cases 
of  pneumonia  in  pregnancy,  and  collected  the  details  of  11  others.  Of  these 
1")  women,  10  had  not  reached  the  sixth  month,  and  4  aborted  the  fourth, 
fifth,  sixth,  and  ninth  days  from  the  commencement  of  the  attack.  In  3 
cases,  the  abortion  was  followed  by  disease  of  the  lungs  of  the  severest  char- 
acter, all  proving  fatal  three  or  four  days  after ;  only  one,  whose  pneumonia 
was  limited,  recovered  without  serious  symptoms.  The  <>  who  did  not  mis- 
carry, died  without  exception  during  the  progress  of  the  disease. 


DISEASES    OCCURRING    DURING    PREGNANCY.  449 

Of  the  5  women  who  had  reached  an  advanced  stage,  2  were  seven  months 
pregnant  when  attacked  with  pneumonia;  one  was  delivered  prematurely  on 
the  twelfth,  and  the  other  on  the  fifteenth  day,  both  dying  two  days  after. 
The  3  others  were  in  their  ninth  month  :  2  were  delivered  of  living  children 
on  the  seventh  and  eighth  day  of  the  disease ;  the  other  died  undelivered  on 
the  fifth  day. 

From  the  preceding  data  it  may  be  concluded,  that  abortion  usually  fol- 
lows an  attack  of  pneumonia  during  pregnancy.  I  think,  says  M.  Grisolle, 
that  its  disastrous  influence  is  explained  by  the  importance  of  the  organ 
affected,  by  the  gravity  of  the  disease,  the  intensity  of  the  general  reaction, 
and  the  numerous  sympathetic  disorders  which  it  produces  in  all  the  func- 
tions, much  rather  than  by  the  paroxysms  of  coughing. 

That  the  pregnant  condition  exerts  a  most  dangerous  influence  upon  the 
disease  is  shown  by  the  fact,  that  of  15  women  11  died,  though  the  general 
state  of  health  was  apparently  very  favorable  in  most  of  them.  The  prog- 
nosis seems  to  be  more  discouraging  before  than  after  the  seventh  month. 
Finally,  if  it  be  allowable  to  conclude  from  so  limited  a  number  of  facts, 
abortion,  contrary  to  what  we  have  seen  in  regard  to  variola,  would  appear 
to  be  rather  favorable  than  otherwise,  since  of  the  4  cases  of  miscarriage  one 
recovered,  whilst  the  6  who  did  not  abort,  all  died.  This  would  seem  to 
confirm  the  following  proposition  of  Desormeaux,  namely :  Abortion,  wrhich 
occurs  but  too  often  in  acute  diseases,  frequently  leads  to  a  favorable  termi- 
nation in  inflammatory  affections. 

3.  Various  Inflammatory  Diseases.  —  We  have  but  very  imperfect  data  by 
which  to  judge  of  the  reciprocal  influence  of  pregnancy  and  of  other  acute 
inflammations.  The  statements  of  authors  in  regard  to  it  are  limited  to  a 
few  isolated  and  often  contradictocy  facts,  whose  very  restricted  number 
allows  no  useful  conclusion  to  be  drawn  from  them. 

Whatever  be  the  acute  affection  from  which  the  pregnant  female  suffers, 
the  treatment  does  not  differ  materially  from  that  which  is  proper  under 
ordinary  circumstances.  So  long  as  there  remains  a  reasonable  hope  of 
saving  the  mother  by  the  use  of  mild  and  innocent  remedies,  none  othnr 
should  be  resorted  to;  but  if  the  disease  be  dangerous,  and  demands  moie 
active  but  more  efficient  means,  it  should  be  treated  as  though  the  woman 
were  not  pregnant.  Bleeding  and  purgation  which  have  been  reproached 
with  a  tendency  to  produce  abortion,  may  doubtless  have  that  effect ;  but  it 
must  not  be  forgotten  that  they  are  used  here  to  combat  an  affection  which 
is,  of  itself,  a  much  more  active  cause  of  abortion,  besides  endangering  the 
mother's  life  so  seriously. 

4.  Icterus.  —  Though  icterus  appears  to  affect  the  pregnant  condition  un- 
favorably, it  is  not  exactly  true  to  say  that  it  always  arrests  its  progress  and 
produces  abortion,  either  as  regards  the  severest  or  the  lightest  cases  of  the 
affection.  I  have  seen  several  cases  of  simple  jaundice  which  constituted 
but  a  slight  indisposition,  and  in  no  degree  affected  the  gestation.  The  con- 
trary has,  however,  been  the  case  in  some  instances,  and  the  two  following, 
quoted  by  M.  Ozanam,  seem  to  me  to  be  evidently  exceptional : 

A  young  primiparous  woman,  five  months  gone,  had  been  sick  lor  live 
days  with  a  very  simple  jaundice,  when  she  entered  the  hospital;  three  day-; 
29 


450  PATHOLOGY   OF    PREGNANCY. 

after,  she  miscarried.  Another,  seven  month's  and  a  half  pregnant,  also 
aborted  five  days  alter  the  commencement  of  a  simple  icterus.  Neither  of 
the  children  presented  a  yellow  hue.     Both  mothers  recovered. 

The  life  of  the  child  is  greatly  endangered  by  its  premature  expulsion, 
though  ii  is  rarely  affected  with  the  mother's  disease.  In  none  of  the  cases 
which  have  come  under  my  notice  did  the  foetus  present  an  icteric  hue, 
although  the  amniotic  fluid  was  more  or  less  colored.  .).  P.  Frank,  how- 
err,  relates  the  case  of  an  icteric  female  who  was  delivered  of  a  jaundiced 
child. 

It  is  rarely  that  what  is  described  as  the  grave  form  of  essential  icterus 
does  not  determine  abortion,  and  it  is  also  rare  for  the  latter  not  to  be  fol- 
lowed by  the  death  of  the  mother.  Thus,  out  of  the  five  cases  reported  by 
Dr.  Kerksig,  in  the  account  of  the  epidemic  which  occurred  in  1794,  there 
were  four  deaths.  M.  Ozauam  relates  the  case  of  a  woman  six  months 
pregnant  who  died  before  miscarrying;  and  my  friend,  Dr.  Fournier,  has 
quite  recently  had  a  case  of  abortion  followed  by  death. 

[Churchill  quotes  the  following  account  by  Dr.  Saint-Yel  of  an  epidemic  of  jaun 
dice  in  the  island  of  Martinique  in  1858. 

"This  icterus,  which  presented  all  the  characters  of  an  essential  disease,  sur- 
prised the  medical   men   by  its  epidemic  character,   and  its  gravity  in   pregnant 

w en,  and   in   them  only.     It  began  at  Saint-Pierre  about  the  middle  of  April, 

reached  its  height  in  June  and  July,  and  having  gone  through  the  colony,  ended 
with  some  isolated  eases  toward  the  close  of  the  year. 

"Attacking  the  various  races  of  which  the  population  consists,  the  white  as  well 
as  the  negro  and  the  Indian  coolie,  the  Huropean  as  well  as  the  Creole,  it  seemed  to 
prefer  adults,  and  was  unattended  with  atfection  of  the  liver.  When  pregnancy 
did  not  exist,  its  termination  was  almost  invariably  favorable.  The  only  victims 
were  women,  amongst  whom  were  three  young  females  not  pregnant,  and  a  woman 
of  sixty-three  years  of  age.  In  these  it  was  always  of  a  grave  character,  always  the 
same,  always  mortal,  and  always  accompanied  by  coma. 

"Of  thirty  pregnanl  women  attacked  at  Saint-Pierre,  only  ten  reached  term  with 
no  other  symptoms  than  those  of  essential  icterus.  The  remaining  twenty  died 
comatose  alter  abortion  or  premature  delivery. 

"  In  the  gravest  cases  in  pregnant  women  the  disease  always  pursued  the  same 
course.  It  always  had  the  essential  form,  and  was  often  light,  until  the  occurrence 
of  abortion  or  premature  delivery,  which  never  took  place  before  the  jaundice  ap 
They  were  generally  brought  about  by  the  latter  after  it  had  existed  for 
two,  or,  less  frequently,  three  weeks.  Until  coma  appeared,  the  symptoms  had  no 
apparent  gravity,  nor  presented  anything  peculiar.  Thecoma  preceded  or  followed 
the  abortion  or  labor  by  a  few  hours,  in  two  cases  only  coming  on  three  days  after. 

"  The  women  who  died  had  reached  the  fourth,  fifth,  sixth,  seventh,  and  eighth 
months  of  gestation.  The  coma  Avas,  in  rare  cases,  preceded  by  a  slight  delirium, 
it  never  for  a  moment  disappeared,  but  grew  more  and  more  profound  until  death 
occurred.  It  lasted  but  for  a  few  hours,  though  in  two  cases  it  continued  for  twenty 
four  and  thirty-six  hours.  Until  it  came  on  there  was  nothing  special  to  be  observed 
in  regard  to  the  general  sensibility,  respiration,  or  circulation.  The  pulse  was  n<  t 
quickened,  nor  had  it  that  slowness  which  is  sometimes  observed  in  cases  of  jaun 
dice.  None  of  the  other  features  of  grave  attacks  of  icterus,  not  even  uterine  hem- 
orrhage, were  observed.  With  perhaps  one  exception,  the  women  who  died  had  no 
hemorrhage  after  delivery,  and  when  death  occurred,  three  or  tour  days  subsequently, 
the  lochia  were  of  a  normal  character. 


DISEASES    OCCURRING     DURING     PREGNANCY.  451 

•'Almost  all  the  childisn  were  still-born,  a  few  only  living  for  a  few  hours, 
whilst  but  one  survived  and  is  still  living.  None  of  thorn  were  jaundiced,  nor  had 
any  of  the  ten  other  children  born  at  term  of  jaundiced  mothers  any  sign  of  the 
disease."     (Saint- Vel,  Gazette  des  Hopitanx,  Nov  20th,  1862.) 

On  the  other  hand,  Dr.  Bardinet  read  in  1863  an  account  of  a  grave  epidemic 
of  icterus  which  prevailed  in  Limoges  from  the  month  of  October,  1859,  to  March, 
1860.  In  13  women  observed  by  him  the  pregnancy  followed  its  regular  course  in 
five  cases  which  were  delivered  safely  at  the  ninth  month.  In  5  others  the  disease 
was  followed  either  by  abortion  or  premature  lahor.  In  the  remaining  3  the  icterus 
assumed  a  grave  form  with  ataxic  symptoms  followed  by  coma,  and  both  mothers 
and  children  soon  perished. 

Both  multiparas  and  primiparge  were  attacked  by  the  disease,  but  all  had  passed 
the  fifth  month  of  gestation.' 

Dr.  Bardinet  recapitulates  as  follows: 

1.  Icterus  may  appear  as  an  epidemic  amongst  pregnant  women. 

2.  It  then  assumes  three  different  forms,  viz. : 

a.  In  the  first  it  is  simple  or  benign  in  character,  and  allows  the  pregnancy  to 
progress  favorably  to  term. 

6.  In  the  second  it  assumes  the  first  degree  of  malignity,  forming  what  might  be 
called  abortive  jaundice,  and  occasioning  either  abortion  or  premature  delivery 
without  other  unfavorable  consequences. 

c.  In  the  third  it  assumes  all  the  characters  of  the  grave  form  of  icterus,  producing 
ataxic  symptoms  and  coma,  which  soon  terminate  the  lives  of  both  mother  and  child. 

II.  Blot,  in  the  excellent  report  from  which  I  have  quoted  the  preceding  facts, 
relates  a  severe  case  of  icterus  observed  by  him  at  the  Hospital  of  theClinique. 
The  patient  died,  and  at  the  autopsy  ecchymoses  were  found  beneath  the  skin,  and 
on  the  surface  of  the  brain,  of  the  heart,  of  the  lungs,  and  of  the  intestinal  canal. 
The  liver  was  small,  and  of  a  deep-brown  color,  without  yellowish  spots.  Micro- 
scopic examination  showed  that  the  tissue  of  the  latter  organ  was  destitute  of  a 
single  trace  of  an  hepatic  cell.  All  the  preparations  showed  merely  fat  globules 
in  abundance  mixed  with  biliary  matter. 

The  cause  of  grave  icterus  during  pregnancy  remains  unknown.  I  am  disposed, 
however,  to  believe  with  M.  Blot  that  it  is  due  to  changes  in  the  liver,  which  I 
described  long  ago  as  occurring  in  pregnant  women.     (See  p.  157.) 

In  regard  to  treatment,  we  are  obliged  to  admit  the  inefficiency  of  all  measures 
employed  up  to  the  present  time.  Premature  labor  or  abortion  would  probably  be 
more  injurious  than  useful.  As  to  prophylaxis,  we  should  not  hesitate  in  case  of 
the  occurrence  of  epidemic  jaundice,  to  advise  pregnant  women  to  change  their 
place  of  residence.] 

5.  Syphilis. — Syphilis  may  have  the  most  disastrous  effect  upon  the  course 
of  gestation,  being  a  very  frequent  cause  of  abortion,  and  especially  of  pre- 
mature labor.  Its  mode  of  action  is  various :  sometimes,  for  example,  the 
mother  is  in  such  a  cachectic  condition  as  to  be  unable  to  provide  the  foetus 
with  the  material  required  for  its  development,  her  enfeebled  constitution 
leaving  the  work  incomplete;  most  generally,  however,  the  health  of  the 
mother  is  not  sensibly  altered,  and  the  action  of  the  poison  seems  to  be 
directed  upon  the  foetus  only.  In  most  cases,  indeed,  the  disease  does  not 
disturb  the  natural  course  of  gestation,  but  attacks  gravely  the  health  of  the 
foetus.  Nothing  is  mo'e  common  than  for  the  latter  to  perish  at  more  or 
less  advanced  periods,  and  be  evpelled  prematurely.  In  these  instances, 
numerous  visceral  lesions  are  discovered  at  the  autopsy :  sometimes  it  is  an 

1  II.  BlcU,  Bulletin  dc  V  Academie  de  Midccine,  October,  18C4. 


452  PATHOLOGY     OF     PKEGN  A.NCY. 

abscess  of  the  thymus  gland  (P.  Dubois);  sometimes  purulent  collectioas  it: 
the  lungs  (Depaul);  sometimes,  again,  is  found  that  singular  alteration  of 
the  liver  so  well  described  of  late  by  M.  Gubler,  or  those  traces  of  peritoneal 
inflammation  and  sero-purulent  effusions  pointed  out  by  Dr.  Simpson  as  due 
;o  the  same  cause.  Neither  is  it  rare  to  find  numerous  bullae  of  pemphigus 
upon  various  parts  of  the  body  of  the  child,  especially  upon  the  soles  of  the 
feet  and  the  palms  of  the  hands.  For  further  details,  see  Diseases  of  the 
Foetus. 

Cases  such  as  we  have  just  mentioned  are,  unfortunately,  but  too  common  ; 
it  is  not,  however,  to  be  understood  that  every  child  born  of  infected  parents 
must  necessarily  suffer  all  the  consequences.  We  even  insist  that  such  is 
not  the  most  frequent  result,  for  considering  the  large  number  of  parents 
who  are  diseased,  or  who  have  been,  the  syphilitic  lesions  of  new-born  chil- 
dren would  be  much  more  frequent  than  is  really  the  case. 

M.  Leo-endre,  in  discussing  the  question  of  the  latent  condition  of  syphilis 
in  the  parents,  and  of  its  influence  upon  the  health  of  the  child,  arrives  at  a 
denial  of  this  influence  in  the  majority  of  cases. 

Of  the  63  patients  who  came  under  my  observation,  he  says,  there  were 
14,  who  had  altogether  68  children,  during  the  period  intervening  between 
the  disappearance  of  the  primary  symptoms  and  the  development  of  the 
venereal  eruption.  Of  this  number,  35  died  without  ever  having  had  an 
eruption  upon  the  body.  The  mean  of  the  ages  of  these  children  at  death 
was  7  years;  the  extremes  being  6  months  and  22  years. 

All  the  33  surviving  children  enjoyed  good  health,  the  mean  of  their 
ages  being  17  years;  the  extremes  1  year  and  38  years. 

[Inasmuch  as  it  is  said  that  syphilis  may  be  transmitted  by  either  parent,  it  is 
far  more  probable  that  it  should  be  when  both  are  diseased.  We  will  examine 
i.nccessively  the  first  two  conditions. 

a.  Transmission  by  the  father.  —  The  father  only  being  syphilitic,  can  he  commu- 
nicate his  disease  to  the  child?  The  question  is,  at  present,  much  disputed,  for 
although  the  affirmative  is  maintained  by  Trousseau,  Diday,  Depaul,  and  Bourgeois, 
a  directly  opposite  opinion  is  arrived  at  by  Cullerier,  who  bases  his  view  upon  the 
observation  of  healthy  children  whose  fathers  were  syphilitic,  but  whose  mothers 
were  not.  He  believes  that  inherited  syphilis  is  always  derived  from  the  mother, 
the  father  having  nothing  to  do  with  it.  The  same  doctrine  is  taught  in  the  memoirs 
of  Notta  and  Charrier,  and  our  colleague  M.  Follin  (Traite  de  Pathologie  Externe) 
has  observed  six  cases  favorable  thereto. 

It  is  not  easy,  therefore,  to  decide  the  question.  For  our  own  part,  we  think  that 
although  the  transmission  of  syphilis  from  the  father  to  the  child  can  hardly  be 
denied  in  some  cases  at  least,  it  is  certainly  less  common  than  has  been  supposed. 

u.  Transmission  by  the  mother.  —  This  cannot  be  doubted.  Two  cases,  however, 
present  themselves:  the  mother  may  be  syphilitic  from  the  period  of  conception, 
or  she  may  not  have  contracted  the  disease  until  after  she  became  pregnant.  In 
the  first  case  there  is  no  dispute  as  regards  the  fact  of  infection,  but  the  unanimity 
ceases  in  the  second  case,  when  the  question  arises  at  what  period  of  gestation  the 
mother  must  be  infected  in  order  that  it  should  be  possible  for  her  to  transmit  the 
disease  to  the  foetus.  Cullerier  thinks  that  it  may  occur  at  any  time  during  preg- 
nancy, whilst  Ricord  would  restrict  the  possibility  to  the  end  of  the  sixth  month, 
and  Abernethy  the  seventh. 

The  opinion  which  would  attribute  to  the  use  of  mercury  the  effect  due  to  the 


DISEASES    OCCURRING    DURING    PREGNANCY.  453 

action  of  syphilis,  is  both  false  and  dangerous.  The  observations  of  M.  Dunal  have 
(thuvvn  that  syphilitic  women  who  had  never  been  treated,  or  if  so,  in  an  imperfect 
manner,  either  aborted  or  were  delivered  prematurely  of  still-born  or  infected 
children  which  died:  with  those,  however,  who  had  the  constitutional  disease  and 
were  treated  by  mercury,  the  success  was  complete  in  many  instances  in  respect 
both  to  mother  and  child. 

6.  Saturnine  intoxication. — Women  exposed  to  lead  poisoning  are  very  liable  to 
abort.  A  former  hospital  interne,  Dr.  Constantine  Paul  (Archives  Generates  de 
Medecine,  May,  1860),  made  a  study  of  the  effects  of  this  action  during  gestation. 
He  observed,  in  1859,  the  case  of  a  woman  who  had  been  three  times  safely  de- 
livered before  being  exposed  to  the  influence  of  lead,  and  who  afterward,  out  of 
ten  pregnancies,  had  eight  miscarriages,  one  child  still-born,  and  but  one  delivered 
at  term,  but  which  died  five  months  afterward.  Struck  by  the  observation,  M. 
Paul  thought  that  this  great  mortality  might  be  due  to  the  action  of  lead.  The 
woman  also  informed  him  that  almost  all  her  companions  in  the  establishment  in 
which  she  worked  either  miscarried  or  were  unable  to  raise  their  children.  Then 
it  was  that  he  began  his  investigations. 

M.  Paul  found  81  cases  of  women  in  whom  saturnine  intoxication  occasioned 
either  the  death  of  the  foetus  or  the  premature  death  of  the  child  after  birth  ;  also 
miscarriages  at  from  3  to  6  months,  and  premature  labors  in  which  the  children 
were  born  either  dead  or  in  a  dying  condition. 

Out  of  a  first  series  of  observations,  4  women  afforded  a  total  of  15  pregnancies,  in 
which  there  were  10  abortions,  2  premature  labors,  1  still-born  child,  1  which  died 
within  twenty-four  hours,  and  1  only  which  survived. 

A  second  set  of  cases  comprises  the  history  of  women  who  had  been  safely  de- 
livered before  exposure  to  the  influence  of  lead,  but  whose  children  afterward  suf- 
fered from  its  effects. 

Another  set  shows  the  alteration  of  results  according  as  the  woman  gave  up  of 
resumed  her  occupation  on  several  different  occasions. 

A  final  series  proves  that  the  foetus  may  die  of  lead  poisoning,  even  though  the 
mother  may  have  had  no  symptom  of  the  intoxication. 

To  recapitulate.  Out  of  123  pregnancies  there  were  64  abortions,  4  premature 
labors,  5  still-born  children,  20  which  died  within  the  first  year,  8  in  the  second, 
7  in  the  third,  and  1  death  at  a  later  period,  14  living  children,  of  whom  10  only 
were  more  than  three  years  old.] 

7.  Phthisis. — Most  authors,  in  writing  upon  this  disease,  have  given  cur- 
rency to  the  idea,  that  its  progress  is  arrested  by  the  occurrence  of  preg- 
nancy, but  that  immediately  after  delivery,  the  pulmonary  affection  ad- 
vanced rapidly  to  a  fatal  termination. 

In  a  work  read  lately  before  the  Academy  of  Medicine,  M.  Grisolle  has 
endeavored  to  determine  the  reciprocal  influence  of  these  two  conditions, 
and  in  so  doing  has  arrived  at  somewhat  different  conclusions  from  those 
which  had  been  received  as  a  general  expression  of  the  truth.  We  think  it 
right  to  give  a  brief  analysis  of  this  memoir. 

Of  seventeen  cases  collected  by  M.  Grisolle,  and  ten  others  furnished  him 
by  M.  Louis,  twenty-four  were  those  of  women  attacked  with  the  disease 
during  pregnancy,  at  periods  not  far  removed  from  its  commencement;  the 
three  others  had  reference  to  individuals  who  presented  the  rational  signs 
of  tuberculosis  at  the  time  of  conception,  but  in  whom  the  disease  became 
well-marked  only  at  a  later  period. 

In  none  of  these  cases  was  the  pulmonary  affection  arrested,  nor  did  it 


ibi  PATHOLOGY  OF  PREGNANCY. 

fail  to  progress  quite  rapidly.  The  symptoms  peculiar  to  tuberculosis, 
whether  local  or  general,  were  developed  with  the  same  order,  the  same 
regularity,  and  the  same  constancy  as  in  the  ordinary  conditions  of  life. 
But,  on  the  other  hand,  contrary  to  what  might  have  been  expected,  the 
pregnant  condition  neither  aggravated,  nor  rendered  more  frequent,  the 
accidents  of  the  disease;  bronchial  hemorrhage  was  noticed  as  being  even 
rather  less  frequent  than  usual. 

The  entire  duration  of  the  phthisis  in  13  women  who  were  followed  to  the 
eiiil  was  rather  shortened  than  otherwise.  Thus,  in  all  of  them  it  lasted  on 
an  average  nine  months  and  a  half,  which  is  a  figure  more  than  a  third  less 
than  that  which  expresses  its  duration  for  women  of  the  same  age,  but  not 
pregnant. 

Pregnancy  lias  not,  therefore,  the  power  of  suspending  phthisis,  which  has 
been  supposed.  But  is  it  true,  as  is  generally  believed,  that  labor,  and  the 
puerperal  condition,  give  to  the  process  of  tuberculization  such  an  unusual 
impulse  as  to  make  it  prove  fatal  in  a  very  short  time?  The  facts  appealed 
to  bv  M.  Grisolle  invalidate  this  opinion  also.  Thus,  12  women,  in  whom 
the  disease  had  reached  the  second,  and  in  most  of  them  the  third  degree, 
at  the  time  of  delivery,  resisted  its  inroads  for  four  months  on  an  average ; 
and  in  all,  the  symptoms  followed  the  progression  that  is  usually  observed. 
In  10  others,  in  whom  the  affection  was  in  the  first  degree,  or  at  the  begin- 
ning of  the  second,  at  the  period  of  delivery,  the  pulmonary  lesion  was 
found  in  3  to  advance  slowly  ;  in  two  only  did  it  exhibit  a  notable  aggra- 
vation; whilst  in  5,  or  one-half  the  number,  there  was  a  considerable 
amelioration  both  of  the  general  health  and  local  symptoms,  without,  how- 
ever, encouraging  the  hope  of  a  cure,  or  of  a  long  suspension  of  the  disease. 

Does  phthisis  exert  an  unfavorable  influence  upon  the  progress  of  gesta- 
tion ?  In  this  point  of  view,  it  may  at  least  be  regarded  as  much  less 
serious  than  pneumonia.  Thus,  of  22  women,  only  3  aborted  in  the  fourth 
and  sixth  months,  3  were  delivered  prematurely  about  the  eighth  month, 
whilst  all  the  others  reached  their  full  time;  however,  in  nearly  two-thirds 
of  the  latter,  the  pulmonary  disease  commenced  in  the  early  months  of 
gestation,  passed  through  all  its  phases,  and  produced  a  deep-seated  cachexia. 

With  one  exception,  delivery  was  accomplished  after  four  or  five  hours 
of  suffering,  which  is  explained  rather  by  the  relaxation  and  want  of  resist- 
ance of  the  soft  parts,  than  by  the  small  size  of  the  children.  Although 
the  latter  were  generally  feeble  and  emaciated,  yet  in  more  than  a  quarter 
of  the  number  the  tissues  were  firm,  the  form  rounded,  and  of  an  embon- 
point contrasting  remarkably  with  the  reduced  condition  of  the  mother. 

In  all  the  patients,  except  those  who  were  in  the  last  stages  of  consump- 
tion, and  who  died  a  few  days  or  weeks  after  delivery,  milk  was  secreted, 
and  in  the  majority  of  cases  so  abundantly,  that  it  was  impossible  to  pre- 
vent them  from  nursing  the  children. 

The  flow  of  milk,  however,  lessened,  or  even  ceased,  within  a  period  vary- 
ing from  one  to  four  weeks;  and  even  this  short-lived  lactation  was  always 
accompanied  by  a  sensible  aggravation  of  the  disease,  and  had  the  most 
disastrous  effects  upon  the  children  ;  for  they  died  shortly  after  of  softening 
of  the  intestinal  mucous  membrane. 


DISEASES     OCCURRING     DURING     PREGNANCY.  455 

From  a  very  interesting  memoir  upon  the  same  subject,  by  M.  Di.hr  ueilh, 
of  Bordeaux,  "it  appears  that  the  result  of  his  observations  has  been  nearly 

the  same.  . 

In  short,  neither  pregnancy  nor  delivery  affect  the  progress  of  phthisis- 
nor  does  the  latter  disturb  sensibly  the  course  of  the  former. 

8.  Hysteria;  Epilepsy;  Chlorosis.  —  Some  physicians  have  imagined 
*hat  the  occurrence  of  pregnancy  might  exert  a  favorable  influence  upon 
hysteria  or  epilepsy,  either  by  suspending  the  attacks  during  the  continuance 
of  gestation,  or  even  by  ridding  the  patients  of  these  affections  entirely. 
Unfortunately  these  hopes  have  not  been  realized  by  experience;  for 
although  the  convulsive  attacks  have  seemed  in  some  cases  to  be  less  fre- 
quenter have  even  ceased  entirely,  in  others,  they  have  occurred  much 
oftener  than  before.  M.  Malgaigne  mentions  a  remarkable  case  in  which 
the  first  epileptic  attack  came  on  during  pregnancy  in  an  unfortunate  female 
who  had  never  before  been  affected  with  it,  and  who  retained  it  throughout 

her  future  life. 

Marriage,  and  the  consequent  pregnancy,. have  often  been  recommended 
as  the  best  means  of  curing  chlorosis.  When  this  disease  appears  to  have 
been  produced  by  disappointed  love,  the  cause  may,  indeed,  be  thus  removed, 
and  the  remedies  directed  against  it  rendered  more  efficacious.  Pregnancy 
may,  in  this  way,  regulate  the  uterine  functions  for  the  future,  cure  the  dys- 
menorrhcea,  and  consequently  have  a  favorable  effect  when  the  irregular  or 
difficult  menstruation  was  the  cause  of  the  chlorosis.  Under  all  other  cir- 
cumstances, however,  pregnancy  has  seemed  to  me  to  aggravate  the  chlorotic 
symptoms.  I,  therefore,  think  it  most  prudent  to  defer  marriage  until  after 
the  general  health  of  the  patient  is  improved. 

§  5.  Surgical  Diseases. 

1.  The  pregnant  condition  often  has  a  favorable  effect  upon  scrofuloiu. 
ulcers.  Under  the  influence  which  it  exerts  upon  the  entire  organism, 
glandular  engorgements  sometimes  disappear,  diseases  of  the  bones  are 
modified  favorably,  ulcers  become  clean  and  covered  with  bright,  firm  granu- 
lations, and  cicatrization  follows. 

In  many  cases,  it  has  appeared  to  arrest  the  consolidation  of  fractures. 
A  curious  instance  of  the  kind  is  mentioned  by  Alanson.  A  woman  broke 
her  tibia  when  in  the  second  month  of  her  pregnancy,  and  during  the  seven 
succeeding  months,  the  solidification  made  no  progress.  Nine  weeks  after 
delivery,  the  callus  was  strong  enough  to  admit  of  walking.  As  proving 
that  no  constitutional  depravation  could  be  adduced  in  explanation  of  the 
retarded  cure,  he  adds,  that  three  months  before  impregnation,  she  had 
recovered  rapidly  from  a  fractured  thigh.  My  friend,  Dr.  Fournier,  cites 
three  analogous  cases  from  Dupuytren's  Clinic.  In  all  three,  there  was  no 
consolidation  before  delivery,  though  it  took  place  rapidly  afterward. 
Though  other  similar  instances  are  on  record,  it  must  he  acknowledged  that 
there  is  also  a  considerable  number  in  which  recovery  did  not  seem  to  he 
delayed  by  the  pregnant  condition. 

2.  Serious  operations  have  several  times  been  performed  during  gestation 
without  producing  abortion,  whilst  in  other  cases  they  have  had  this  result. 


156  PATHOLOGY  OF  PREGNANCY. 

From  these  opposite  facts,  I  think  it  fair  to  conclude  that  none  but  indent 
operations  should  be  performed,  and  that  all  others,  such  as  fistula  in  ano, 
for  example,  which  do  not  endanger  the  life  of  either  mother  or  child, 
should  be  deferred  to  another  time. 

3.  Tumors  in  the  Abdomen  and  Pelvis. — Most  authors  think  that  tumors 
in  the  abdomen  and  pelvis  during  pregnancy,  have  no  other  effect  than  to 
impede  mechanically  the  development  of  the  uterus,  or  to  present  an 
obstacle  to  the  delivery.  (See  Dystocia.)  Sometimes,  however,  they  assert, 
they  may  give  rise  to  abortion  or  premature  delivery,  though,  generally, 
thev  are  not  otherwise  dangerous. 

That  this  complication  is  of  no  danger,  independent  of  the  risk  of  abor- 
tion which  it  may  occasion,  cannot  be  admitted  in  an  absolute  sense.  Dr. 
Ashwell  has  remarked,  in  his  excellent  work,  that  the  uterus,  when  de- 
veloped until  term,  exerts  a  strong  compressing  force  upon  the  pathological 
tumor;  that  this  compression  may  give  rise  to  an  inflammation  ending 
sometimes  in  suppuration  at  the  centre  of  the  diseased  mass,  at  others,  in  a 
rapid  increase  of  the  tumor  immediately  after  delivery.  I  have  several 
times  had  the  opportunity  of  verifying  the  accuracy  of  these  statements. 
Death  may  occur  in  a  short  time,  as  the  consequence  of  this  inflammation 
or  rapid  enlargement,  and  the  autopsy  has  several  times  exhibited  the  uterus 
in  a  perfectly  healthy  state,  together  with  the  more  or  less  extensive  altera- 
tion of  the  pathological  tumor. 

Deeply  impressed  by  the  cases  of  this  kind  which  he  had  occasion  to 
observe,  Dr.  Ashwell  asks,  whether  the  development  of  the  uterus,  and  the 
pressure  which  it  exerts  upon  the  neighboring  tumor,  are  not  the  causes  of 
the  pathological  changes  of  the  latter,  and  consequently  whether  the  induc- 
tion of  premature  labor  would  not  be  the  surest  means  of  guarding  against 
the  dangers  to  which  the  female  is  so  often  exposed  in  these  cases,  even  after 
having  overcome  all  the  difficulties  of  labor.  -When  treating  hereafter  of 
premature  labor,  we  shall  have  occasion  to  criticise  the  affirmative  decision 
which  he  has  come  to  ;  but  we  have  thought  it  right  to  direct  attention  to 
a  peculiarity  but  little  known  in  the  history  of  the  tumors  which  complicate 
pregnancy. 

4.  In tra-parietal  fibrous  tumors,  or  those  developed  in  the  substance  of  the 
walls  of  the  uterus,  may  exert  an  injurious  influence  upon  the  course  of 
gestation,  and  become  a  cause  of  abortion  when  they  are  of  large  size ; 
though,  generally,  they  have  no  effect  whatever  when  small.  In  the  latter 
case,  the  physiological  evolution  of  pregnancy  may  accelerate  wonderfully 
the  increase  of  the  pathological  tumor.  The  usually  slow  growth  of  these 
in  tra-parietal  tumors  is  well  known  ;  now  I  have  known  them  in  several  in- 
stances to  acquire  a  size  in  the  first  three  or  four  months,  which  they  would 
not  have  done  in  several  years  in  the  non-pregnant  condition.  Developed 
as  they  are  in  the  midst  of  the  uterine  fibres,  they  participate  in  the  in- 
creased vitality  with  which  the  latter  are  endowed  during  gestation;  and, 
like  them,  they  undergo  a  considerable  hypertrophy. 

In  some  cases  I  have  seen  this  hypertrophy  of  the  morbid  tumor  continue, 
and  .'vcn  increase  after  delivery ;  but  in  others,  the  latter  event  was  followed 
bva  notable  diminution  of  the  size  of  the  tumor,  which  gradually  grew  less 


DISEASES     OCCURRING     DURING     PREGNANCY.  451 

its  the  womb  resumed  its  normal  condition,  finally  attaining  the  size  which 
it  had  before  conception.  In  one  case,  observed  in  1852,  this  process  jf 
absorption  went  on,  and  the  tumor  disappeared. 

\l  6.  Hypertrophy  of  the  Thyroid  Gland. 

It  is  by  no  means  rare  for  the  thyroid  gland  to  undergo  hypertrophy  during  ges*- 
tation  apart  from  any  endemic  influence.  The  enlargement  is  generally  slight  and 
gives  no  trouble,  though  some  women  complain  that  their  necks  become  large  and 
unsightly.  The  swelling  diminishes  somewhat  after  delivery,  though  it  rarely  dis- 
appears entirely. 

I  knew  one  case  in  which  the  hypertrophied  gland  inflamed  and  suppurated, 
giving  rise  to  an  abscess  which  discharged  for  a  long  time;  nor  was  the  cure  com- 
plete until  after  the  lapse  of  several  months. 

Although  this  hypertrophy  of  the  thyroid  gland  in  pregnant  women  is  not  usually 
dangerous,  it  may  in  some  very  rare  cases  imperil  the  life  of  the  patient.  Two 
instances  of  this  kind  are  related  by  M.  N.  Guillot.  The  first  was  that  of  a  lady 
who  was  surprised  during  her  first  pregnancy  to  find  that  the  front  of  her  neck 
was  gradually  enlarging.  When  again  pregnant,  the  swelling  increased  and 
became  uncomfortable  ;  still,  the  delivery  was  favorable,  and  she  nursed  the  child 
for  fourteen  months.  The  gland,  however,  continued  to  enlarge,  respiration 
became  painful,  and  finally  the  symptoms  were  so  threatening  that  tracheotomy 
was  performed.     The  patient  died. 

In  the  second  case,  the  hypertrophy  also  appeared  during  the  first  pregnancy 
and  increased  during  the  succeeding  one,  so  that  nineteen  months  after  the  second 
delivery  it  formed  a  tumor  of  about  eight  inches  in  circumference. 

The  breathing  was  obstructed,  slow,  and  whistling,  during  both  expiration  and 
inspiration,  and  the  voice  was  broken  and  painful.  Paroxysms  of  suffocation  came 
on,  during  one  of  which  the  patient  died.  At  the  autopsy  the  trachea  was  found 
to  be  flattened  and  the  pneumogastric  nerves  compressed. 

I  witnessed  for  myself  a  similar  case  at  the  hospital  of  the  Clinique  in  1861.  A 
woman,  who  for  a  long  time  had  a  goitre,  found  the  tumor  to  increase  rapidly  in 
size  during  her  first  pregnancy.  At  the  sixth  month,  respiration  had  become  very 
difficult,  and  attacks  of  suffocation  brought  her  to  the  hospital.  By  the  end  of  the 
eighth  month  the  symptoms  were  so  severe  that  premature  labor  had  to  be  induced, 
but  the  patient  died  in  an  attack  of  suffocation  a  few  hours  after  delivery.  My 
friend  Dr.  Tillaux,  then  prosector  of  the  Faculty,  dissected  the  tumor  and  found  the 
trachea  compressed  by  the  enlarged  gland.] 

§  7.  Ulcerations  of  the  Neck  of  the  Uterus. 

It  is  rarely  that  cancerous  affections  of  the  neck  of  the  womb  seem  to 
disturb  the  course  of  gestation,  and  the  impediments  which  they  but  too 
often  present  during  labor  prove  sufficiently  that  they  are  rarely  a  cause  of 
miscarriage.  On  the  other  hand,  I  have  never  observed  that  the  increase 
or  degeneration  of  these  tumors  was  sensibly  hastened  during  gestation. 
Therefore,  I  shall  treat  no  further  here  of  this  subject,  reserving  its  discussion 
for  the  article  on  tedious  labor;  but  propose  to  speak  briefly  of  ulcerations 
of  the  neck  during  rvegnancy. 

It  has  been  but  a  short  time  since  surgeons  have  used  the  speculum  in  the 
cases  of  pregnant  women.  A  just  fear  of  the  mischievous  effect  which  might 
follow  its  repeated  introduction  prevented  them  from  obtaining  a  correct  idea 
of  the  condition  of  the  neck  at  the  various  stages  of  pregnancy.    These  fears 


458  PATHOLOGY    OF     PREGNANCY. 

were,  however,  somewhat  exaggerated,  for,  if  introduced  carefully,  the 
speculum  never  causes  serious  accidents.  In  all  cases,  the  instrument  with 
two  or  four  valves  is,  in  my  opinion,  the  best. 

In  default  of  great  experience,  there  is  considerable  difficulty,  no  matter 
what  instrument  be  used,  in  engaging  the  cervix  in  the  extremity  of  thp 
speculum,  unless  the  situation  of  the  neck  is  first  ascertained  by  the  touch 
This  difficulty  is  known  to  result  from  the  fact  of  the  direction  of  the  cervix 
toward  the  anterior  surface  of  the  sacrum. 

The  engagement  once  effected,  it  is  only  necessary  to  separate  the  vahea 
of  the  instrument  slightly  in  order  to  bring  the  os  tincae  into  view. 

A-  the  touch  should  have  led  to  anticipate,  the  changes  which  the  eye 
detects  in  the  intra-vaginal  portion  of  the  neck,  are  very  different  in  the 
primiparous  female  from  what  they  are  in  one  who  has  had  children;  we 
would  also  add,  that  the  appearance  is  far  from  identical  at  the  beginning 
and  termination  of  pregnancy. 

As  seen  in  the  latter  third  of  gestation,  the  neck  is  generally  of  a  deep 
violet-red  color;  and,  if  it  be  a  first  pregnancy,  is  usually  quite  smooth 
throughout  its  extent;  the  external  orifice  is  ordinarily  more  or  less  rounded, 
and  though  larger  than  in  the  unimpregnated  condition,  it  barely  permits 
the  sight  to  penetrate  its  cavity,  even  though  the  valves  of  the  instrument  be 
separated  considerably.  The  circumference  of  the  external  orifice  and  the 
free  portion  of  the  neck  rarely  exhibit  signs  of  ulceration,  though  it  is  quite 
common  to  observe  a  series  of  granulations  of  a  cherry-red  color,  of  sizes 
varying  from  that  of  a  large  pea  to  that  of  a  pin's  head.  These  species  of 
vegetations  bleed  upon  the  slightest  touch  with  the  cotton  used  for  wiping 
them. 

In  the  female  who  has  had  several  children,  the  neck  is  usually  much  less 
voluminous,  and  it  is  somewhat  difficult  to  include  it  entirely  in  the  speculum. 
The  lips  of  the  os  tincse  seem  divided  in  several  portions,  a  sort  of  segmenta- 
tion caused  by  the  ruptures  which  occurred  in  the  preceding  labors,  and  which 
give  to  the  orifice  considerable  irregularity.  In  consequence  of  these  numer- 
ous solutions  of  continuity,  the  opening  is  much  larger,  and  is  dilated  with 
great  facility,  provided  the  valves  be  separated,  thus  allowing  the  eye  tc 
explore  the  cavity  with  readiness. 

The  walls  of  this  cavity  are  very  unequal,  frequently  presenting  an  unin- 
terrupted series  of  fungous  projections,  separated  by  depressions  of  variable 
depth.  Home  of  these  projections  are  transparent,  being  formed  probably 
by  hypertrophied  follicles;  others  resemble  soft  vegetations.  The  latter  are 
generally  covered  by  an  intact  epithelium,  so  that  they  may  be  touched 
without  being  made  to  bleed  ;  again,  what  is  by  no  means  rare,  they  seem 
destitute  of  this  external  covering,  and  bleed  upon  the  slightest  touch. 

It  is  more  especially  in  the  furrows  which  separate  these,  that  linear  ulcera- 
tions of  variable  depth  are  discoverable.  These  ulcerations  sometimes 
extend  over  a  considerable  surface,  and  are  then  readily  perceived,  though 
they  are  usually  concealed  in  the  depth  of  the  anfractuosities,  and,  in  order 
to  see  them,  it  is  necessary,  after  a  thorough  cleansing,  to  unfold  the  neck, 
as  it  were,  by  expanding  the  speculum  considerably. 

According  to  MM.Gosselin,  Danyau,  and  Costilhes,  these  linear  ulcera- 


DISEASES    OCCURRING    DURING    PREGNANCY.  459 

lions  are  much  less  frequent  than  I  had  supposed,  and  are  met  with  in  barely 
tnoie  than  half  the  cases,  whilst  I  had  observed  them  iu  seven-tighths. 
However,  as  I  stated  very  plainly,  I  intended  to  be  understood  as  speaking 
only  of  multipara?  who  had  reached  the  latter  months,  whilst  M.  Gosselin 
includes  in  his  statement  all  stages  of  pregnancy,  and  M.  Danyau  does  not 
appear  to  have  distinguished  primipara  from  multipara?. 

Must  we  admit  that,  as  M.  Huguier  supposes,  we  have  been  deceived  ? 
According  to  this  gentleman,  a  muco-pus  of  variable  consistence  is  frequently 
deposited  in  and  adheres  closely  to  the  bottom  of  the  furrows  observed  on 
the  internal  surface  of  the  neck.  This  matter  bears  a  complete  resemblance 
to  the  bottom  of  an  ulcer;  but  efface  the  folds  and  wipe  them  well,  and  the 

supposed  ulcerations  disappear It  is  difficult  for  us  to  believe  that  we 

have  been  so  deceived ;  still,  the  assertion  of  M.  Huguier  merits  serious 
attention,  and  shall  receive  it  hereafter. 

Unless  my  observations  have  been  for  a  long  time  subject  to  a  series  of 
singular  coincidences,  it  is  probable  that  what  we  have  just  described  is  the 
normal  condition,  and  should  not  be  regarded  as  pathological,  but  simply 
as  a  consequence  of  the  progress  of  gestation.  As  the  violet- red  color,  the 
swelling,  the  softening,  and  the  almost  fungous  condition  of  the  walls  of  the 
neck,  are  peculiar  to  pregnancy,  and  in  no  wise  interfere  with  its  progress, 
so  I  regard  the  ulcerations  as  a  consequence  of  a  physiological  process, 
extreme  in  degree,  and  of  no  greater  importance  than  the  other  physiological 
changes. 

Especially  am  I  convinced  of  their  non-injurious  character,  and  therefore 
regard  all  treatment  employed  against  these  ulcerations,  even  when  fungoid, 
as  much  more  hurtful  than  useful.  I  say,  even  fungoid;  for,  contrary  to  the 
opinion  of  M.  Coffin,  who  attributes  a  great  prognostic  value  to  this  character 
of  the  ulceration,  I  think  that  they  are  fungoid,  not  because  they  have  a 
natural  tendency  to  become  so,  but  because  the  tissue  which  they  affect 
always  presents  at  a  certain  period  the  color  and  consistence  of  fungous 
tissue. 

If,  therefore,  I  am  not  deceived,  and  if  the  peculiarities  just  described 
really  form  a  part  of  the  pregnant  condition,  and  are  merely  an  exaggeration 
of  the  changes  which  the  structure  and  vascularity  of  the  walls  of  the  uterus 
undergo  at  this  period,  the  condition  should  disappear  with  the  cause  which 
produced  it.  Like  the  vomitings,  varices,  hemorrhoids,  and  other  sympa- 
thetic disorders  of  pregnancy,  it  should  disappear  with  it.  Now  this  is 
exactly  what  happens,  and  it  may  be  regarded  as  a  principle,  that  no  traces 
of  it  remain  two  months  after  delivery.  The  non-specific  ulcerations  some- 
times met  with  in  recently  delivered  women  are  of  different  appearance,  and 
have  their  origin,  in  my  opinion,  in  the  non-cicatrization  of  the  ruptures 
which  took  place  during  labor. 

In  short  therefore,  the  fungous  condition  of  the  neck,  and  the  ulcerations 
of  greater  or  lesser  depth  which  complicate  this  state  of  the  parts  near  the 
termination  of  pregnancy,  seem  to  me  to  be  the  consequence  of  the  active  or 
passive  congestion  with  which  the  organ  is  affected.  I  think  that,  except  in 
a  few  rare  instances  marked  by  specificity  of  character,  or  strong  tendency 
to  spread, — a  tendency,  by  the  way,  which  I  have  never  observed, — all  local 
treatment  should  be  refrained  from. 


itiO  PATHOLOGY    OF    PREGNANCY. 

Is  the  case  the  same  at  a  less  advanced  period,  and  are  the  uleerawuns 
which  may  affect  the  neck  in  the  early  months  of  an  equally  innoxious 
character  ? 

MM.  Boys  de  Loury,  Costilhes,  Coffin,  and  Bennett,  who  have  directed 
their  attention  more  particularly  to  the  ulcerations  occurring  in  the  first  half 
of  gestation,  have  been  so  forcibly  struck  with  their  tendency  to  produce 
aborti  >n  and  puerperal  diseases,  that  they  class  them  with  the  most  common 
causes  of  miscarriage.  Mr.  Bennett  goes  so  far  as  to  call  them  the  keystone 
of  all  diseases  of  the  pregnant  female,  and  the  most  frequent  cause  of 
difficult  labors,  obstinate  vomiting,  (see  page  465,)  moles,  abortion,  and 
hemorrhage. 

Notwithstanding  the  smallness  of  their  number,  the  observations  which  I 
have  been  able  to  make  differ  so  completely  from  the  results  obtained  by 
these  gentlemen,  that  I  was  tempted  to  accuse  them  of  some  exaggeration. 
Hovcver,  after  having  heard  MM.  Huguier,  Gosselin,  Danyau,  Cloquet,  &c, 
proclaim  the  innocence  of  these  ulcerations,  I  have  no  hesitation  in  saying 
that  they  have  misconstrued  the  facts  observed  by  them.  Finally,  we  would 
add,  that  after  having  read  their  observations,  there  seemed  reason  for 
inquiring  whether,  in  many  cases,  syphilis  may  not  have  been  the  principal 
cause  of  the  accidents,  and  in  others,  whether  the  frequent  introduction  of 
the  speculum  and  the  numerous  cauterizations  which  had  been  practised, 
may  not  have  played  the  most  important  part  in  the  production  of  the 
abortions. 

I  ought,  perhaps,  to  except  the  peculiar  species  of  ulceration  described 
by  my  friend  M.  Richet.  All  the  varieties  of  ulceration,  says  this  learned 
surgeon,  which  are  observed  in  non-pregnant  women,  may  occur  during 
pregnancy ;  but  it  has  seemed  to  me  that  they  had  a  tendency  in  some  cases 
to  assume  a  fungous  character,  to  excavate  the  lips  of  the  cervix,  to  bleed 
readily,  and  give  rise  to  serious  accidents :  abortion,  for  example.  In  all 
my  patients,  these  ulcerations  with  well-defined  edges,  and  red  and  bleeding 
bottoms,  were  covered  with  reddish  fungosities,  which  projected  between  the 
partly  opened  lips  of  the  cervix.  Of  six  patients,  four  miscarried,  and  two 
left  the  hospital  apparently  cured ;  of  the  four  who  aborted,  one  only  had 
been  cauterized,  the  three  others  not  having  undergone  any  treatment. 

Whoever,  like  myself,  has  examined  women  at  the  end  of  gestation,  will 
find  the  ulcerations  observed  by  M.  Richet  in  the  early  months,  and  which 
he  has  had  the  kindness  to  show  me,  to  bear  a  close  resemblance  to  those 
sometimes  met  with  in  the  latter  stages.  I  see  no  difference  except  in  the 
rather  greater  extent  of  the  ulceration.  Their  size  leads  me  to  suppose  that 
their  origin  dates  back  long  before  impregnation,  and  their  sharp,  well- 
defined  edges  excite  a  suspicion  of  their  being  specific  in  character  (five  of 
these  six  women  had  syphilis  at  the  time,  or  had  previously  been  affected  with 
it).  Now  we  may  readily  conceive  that  under  such  circumstances  the  soft- 
ening, congestion,  and  fungous  condition  which  pregnancy  usually  produces 
at  an  advanced  period,  may  here  take  place  prematurely,  and  give  to  the 
ulcerated  tissues  the  livid  hue  and  fungous  aspect  described  by  M.  Richet. 
Thus,  we  may  understand  how  such  an  affection  of  the  cervix,  connected 
most  frequent ly  with  a  general  disorder,  under  whose  influence  it  has  a  con- 


DISEASES    OF    PREGNANCY.  461 

etant  tendency  to  increase,  may  ultimately  give  rise  to  abortion.  Tt  alsc 
seems  to  me  important  to  distinguish  the  ulcerations  which  existed  before 
pregnancy,  and  continued,  and  even  increased  after  conception,  from  those 
which  were  developed  after  the  formation  of  the  germ :  the  former,  in  con- 
sequence of  the  irritation  which  they  may  suffer  as  a  consequence  of  fatigue, 
and  especially  of  too  frequent  coition,  might  readily  excite  the  contractility 
of  the  uterus  and  occasion  miscarriage;  the  latter,  on  the  contrary,  should. 
it  seems  to  me,  rarely  exert  such  an  influence. 

I  agree,  therefore,  with  the  opinion  of  M.  Richet,  that  when  an  ulceration 
presents  in  the  first  half  of  gestation,  possessing  the  characters  which  ho 
describes,  and  which,  in  my  opinion,  are  an  evidence  of  its  chronicity,  mis- 
carriage should  be  anticipated,  and  means  be  taken  to  prevent  it.  Now, 
aside  from  a  specific  treatment  in  those  cases  which  indicate  it,  I  may  be 
allowed  to  ask  of  those  who  would  have  these  ulcerations  treated  as  a  matter 
of  necessity,  what  are  the  best  local  means  to  be  used  ?  Which  caustic  is 
preferable?  Is  not  the  solid  nitrate  of  silver  accused  of  producing  abortion 
by  the  partisans  of  the  caustic  of  Filhos,  of  the  acid  nitrate  of  mercury,  or 
of  the  actual  cautery ;  and  has  not  each  of  these  latter  means  also  been 
reproached  with  giving  rise  to  miscarriage  ?  The  thesis  of  M.  Coffin  affords 
some  curious  details  on  this  subject,  and  evidently  proves,  that  though  cauter- 
ization by  any  agent  whatever  may  claim  some  doubtful  successes,  the  latter 
are  generally  compromised  by  the  abortions  which  have  followed  it.  From 
the  statements  of  Bennett  and  Boys  de  Loury,  the  same  inference  follows. 
M.  Coffin  himself,  though  attributing  such  great  importance  to  these  ulcer- 
ations, arrives  at  this  discouraging  therapeutic  conclusion,  viz.,  thus  far,  nc 
treatment  has  succeeded,  and  the  question  remains  open.  This,  which  was 
true  in  1851,  is  so  still;  for  quite  recently  we  heard  M.  Chassaignac  speak 
emphatically  of  the  inefficiency  of  all  methods,  and  M.  Richet  declares 
bimself  undecided  as  to  the  best  course  to  pursue. 

The  insufficiency  of  local  treatment,  and  the  mischievous  effect  which  it 
may  have  upon  the  progress  of  gestation,  should,  it  seems  to  me,  in  the 
present  condition  of  science,  lead  us  to  dispense  with  it  whenever  the  ulcer- 
ation has  no  marked  tendency  to  invade  a  large  extent  of  the  cervix. 


CHAPTER    II. 

DISEASES    OF    PREGNANCY. 

Tftose  who  have  studied  the  various  affections  of  the  womb  are  well  aware 
that  its  diseases  excite  numerous  sympathetic  disorders.  The  commence- 
ment of  the  physiological  acts  which  devolve  upon  it,  and  their  periodical 
fulfilment,  exert  upon  the  functions  of  the  alimentary  canal,  and  upon  those 
of  the  nervous  system,  an  influence  which  has  for  a  long  time  attracted  the 
attention  of  practitioners.  It  were  useless  to  mention  all  the  morbid  phe- 
nomena which  sooften  precede,  accompany,  and  follow  (he  first  menstruation. 
The«e  are  more  striking  when  the  latter  is  postponed  or  difficult.     In  som« 


462  PATHOLOGY     OF     PREGNANCY. 

inclivi  Juals  they  appear  at  eaeli  menstrual  period  for  a  long  time,  thus  seem- 
ing to  show  an  impossibility  on  the  part  of  the  organ  to  perform  its  functions, 
without  occasioning  extensive  disturbances  of  the  economy;  and  it  is  only, 
so  to  speak,  when  the  sensibility  of  the  womb  has  been  blunted  by  habit, 
that  the  return  of  the  menses  ceases  to  produce  the  general  disorders  which 
accompanied  it  previously. 

If  the  diseases  of  the  organ,  and  even  the  simple  monthly  congestion,  are 
capable  of  giving  rise  to  such  troubles,  it  is  easy  to  foresee  that  pregnancy, 
which  changes  simultaneously  the  form,  size,  and  even  the  structure  of  the 
uterus,  can  hardly  pass  through  its  various  periods  without  deeply  affecting 
all  the  functions. 

The  effects  produced  by  the  pregnant  condition  vary  greatly,  as  regards 
both  the  degree  and  the  nature  of  the  symptoms;  all  of  them  being  influ- 
enced  by  the  constitution  of  the  female.  Occasionally,  it  results  in  a  salu- 
tary change  in  the  entire  system,  better  health  being  then  enjoyed  than  at 
any  other  period.  In  the  majority  of  cases,  however,  tiresome,  or  at  least 
very  disagreeable  symptoms  are  experienced,  which  are  the  expression  of 
the  unpleasant  influence  exerted  by  the  uterus  upon  important  functions. 
The*e  troubles,  which  are  so  slight  in  some  individuals  as  to  amount  merely 
to  discomforts,  are,  in  other  cases,  so  great  as  to  injure  their  health,  and  even 
to  excite  fears  for  their  existence. 

These  accidents  may  appear  at  almost  any  time  ;  for  though  some  persons 
;  to  suffer  at  the  very  outset,  and  are  relieved  by  the  third,  fourth,  or 
fifth  month,  others  are  attacked  only  in  the  latter  half  of  gestation. 

The  pregnant  condition  operates  differently  at  the  different  periods  of 
gestation,  in  the  production  of  the  accompanying  discomforts  or  diseases;  this 
fact,  which  is  important  in  a  therapeutical  point  of  view,  was  felt  vaguely 
to  be  so  by  Burns,  but  clearly  expressed  by  M.  Beau,  who,  I  think,  has 
thrown  much  light  upon  the  pathology  of  pregnancy. 

Most  of  the  functional  disturbances  may  occur  in  the  early,  as  well  as  in 
the  latter  months.  At  first  they  were  regarded  as  the  result  of  the  numerous 
sympathies  existing  between  the  uterus  and  the  digestive  apparatus,  and,  at 
a  later  period,  the  purely  mechanical  difficulties  produced  in  the  neighbor- 
ing organs  by  the  pressure  of  the  uterine  tumor  were  thought  to  assist  in 
their  production.  Now,  the  pressure  of  the  womb  is  of  quite  secondary 
importance,  if,  indeed,  it  be  of  any  whatever;  for,  according  to  M.  Beau, 
I  he  following  is  what  usually  occurs:  The  womb,  as  modified  by  pregnancy, 
affects  the  digestive  functions  through  sympathy,  giving  rise  to  the  dyspeptic 
symptoms  described  hereafter.  The  disturbance  of  these  results  necessarily, 
it'  prolonged,  in  deficient  nutrition,  which,  in  a  woman  who  is  obliged  to 
furnish  the  material  for  the  development  of  the  child,  must  soon  occasion 
iter  or  less  diminution  of  the  blood  corpuscles,  and  a  considerable 
increase  of  the  serum ;  in  short,  to  all  the  anatomical  characteristics  of 
chlorosis  or  polyamia. 

Now,  this  impoverishment  of  the  blood  soon  occasions  new  morbid  symp- 

Loms  in  the  pregnant  woman,  as  well  as  in  the  young  chl orotic  female,  and 

60  serves  to  explain  the  reappearance  of  the  disorders  of  digestion,  verti- 

headaches,  congestions  of  the  face,  palpitations,  and  difficult  respira- 


DISEASES     OF     PREGNANCY.  463 

tion,  so  frequently  observed  at  an  advanced  period  of  pregnancy.  "We 
thus  see  that  the  functional  disorders,  which  at  the  outset  are  purely  sympa- 
thetic, become  afterward  intimately  connected  with  the  chlorosis  which  they 
themselves  helped  to  produce.  (See  Disorders  of  the  Circulation.)  Though 
we  shall  have  occasion  to  treat  hereafter  of  this  latter  etiological  peculiarity, 
we  cannot  help  calling  attention,  at  present,  to  the  importance  of  taking  it 
into  consideration  in  the  choice  of  remedial  measures.  For,  though  it  be 
proper  at  the  commencement  to  reduce  the  over-excitement  of  the  uterus,  and 
the  sympathetic  irritation  produced  by  it  in  other  organs,  by  soothing  reme- 
dies, as  baths,  mild  laxatives,  antispasmodics,  and  sometimes  even  by 
moderate  blood-letting,  an  entirely  different  course  should  be  pursued  toward 
the  end  of  gestation.  All  the  restorative  agents,  as  iron,  animal  food,  and 
tonic  wines,  are  here  the  surest  means  of  opposing  the  plethora  and  removing 
the  disorders  which  it  occasions.  Still,  it  is  right  to  observe,  that  beside  the 
chlorosis,  which  plays  the  principal  part  in  the  production  of  the  disorders 
of  the  latter  months,  the  uterus  still  retains  its  sympathetic  influence,  and 
is  subject  at  all  times  to  congestions,  which  increase  its  irritability,  and 
cause  it  to  react  upon  other  organs;  of  all  which  account  should  be  taken 
in  the  treatment.     The  subject  will  claim  attention  hereafter. 

Finally,  the  connection  which  we  have  endeavored  to  demonstrate  as 
existing  between  the  sympathetic  troubles  of  the  beginning  of  pregnancy 
and  the  chlorosis  of  the  latter  months,  cannot  always  be  readily  discovered. 
The  sympathetic  influence  of  the  uterus  upon  the  digestive  functions  is  not 
always  manifested  by  vomitings,  nausea,  and  strange  and  depraved  appetites. 
All  these  symptoms  may  be  wanting,  and  yet  the  stomach  fail  to  perform 
its  functions  with  its  normal  regularity.  Nutrition  may  be  disordered, 
giving  rise  to  a  dyspepsia,  which  M.  Beau  proposes  to  distinguish  as  latent; 
a  dyspepsia  which  cannot  fail  to  occasion  eventually  a  general  deterioration 
of  the  blood.  Exactly  the  same  thing  occurs  in  young  girls  whose  menstrua- 
tion is  either  difficult,  irregular,  or  imperfect.  Confirmed  chlorosis  is  always 
preceded  in  them  by  sympathetic  disorders  of  digestion ;  though  sometimes 
the  deranged  function  is  evinced  by  very  marked  symptoms,  at  others  it  is 
hardly  a  cause  of  discomfort. 

Desormeaux,  in  his  excellent  article  on  this  subject,  ranges  all  the  diseases 
of  pregnancy  under  the  following  heads,  viz.:  lesions  of  digestion,  of  circu- 
lation, of  respiration,  of  the  secretions  and  excretions,  of  locomotion,  and 
of  the  sensorial  and  intellectual  functions.  And  we  propose  partly  to  adopt 
the  same  order  in  our  description. 

ARTICLE    I. 

lesions  of  digestion. 

§  1.  Anorexia. 

The  want  of  appetite,  or  the  disgust  for  aliments,  which  pregnant  women 
are  so  often  affected  with  towards  the  end  of  gestation,  and  still  more  fre- 
quently at  its  commencement,  may  be  referred  to  various  causes,  and  con 
sequently  will  present  different  indications  for  treatment.     When  it  seems 
to  result  merely  from  the  sympathetic  relations  existing  between  the  uterus 


I'il  PATHOLOGY    OF    PREGNANCY. 

and  the  organs  of  digestion,  there  is  little  or  nothing  to  be  done,  for  it  would 
he  in  vain  to  attempt  removing  the  disgust  which  some  patients  have  to 
certain  articles  of  food.  In  general,  they  dislike  all  meats,  and  this  is  an 
indication,  or  rather  an  obligation,  to  permit  the  use  of  vegetables  in  such 
cases.  Again,  if  at  an  advanced  stage,  the  anorexia  be  accompanied  or 
preceded  by  the  phenomena  of  general  plethora,  venesection,  proportioned  to 
the  general  condition  of  the  female  and  the  stage  of  pregnancy,  may  relieve 
it.  Care,  however,  should  be  observed  not  to  mistake  the  symptoms  pro- 
duced by  anaemia  for  the  indications  of  plethora;  the  former  being  far 
more  effectually  treated  by  ferruginous  preparations.  (See  Disorders  of  the 
Circulation.) 

In  those  cases  which  exhibit  evident  signs  of  an  overloaded  condition  of 
the  alimentary  canal,  some  purgative,  such  as  rhubarb,  or  even  the  neutral 
salts,  may  be  administered.  Indeed,  certain  authors  have  recommended 
an  emetic,  when  there  is  any  gastric  distress;  but  I  think  practitioners 
ought  to  be  very  reserved  in  the  employment  of  this  last  measure,  since  the 
shock  of  vomiting  has  often  produced  abortion. 

§  2.  Pica,  or  Malacia  ;  Pyrosis. 

Pica,  or  malacia,  frequently  accompanies  the  affection  just  described. 
Pregnant  women,  like  chlorotic  girls,  often  have  irregular  and  depraved 
longings  for  the  most  absurd  or  disgusting  articles.  For  instance,  I  have 
known  a  young  female  to  eat  pepper-grains  almost  continually.  Another, 
at  the  Clinique,  scraped  the  walls  to  appease  her  cravings  for  chalk  ;  and 
M.  Dubois  often  relates  in  his  lectures  the  history  of  a  young  pregnant 
woman  whose  greatest  pleasure  consisted  in  eating  small  bits  of  well-charred 
wood.  Again,  they  have  been  observed  eating  greedily  substances  that  are 
still  more  disgusting.  Unfortunately,  all  our  persuasions  are  useless  with 
such  monomaniacs  in  the  majority  of  instances,  and  consequently  we  must, 
as  a  general  rule,  grant  them  an  indulgence,  and  avoid  too  strong  an  oppo- 
sition, unless  the  coveted  articles  would  evidently  be  injurious  to  their  health. 

I  have  but  little  to  say  of  the  acidity  of  stomach,  of  the  spasmodic  pains 
of  that  organ,  and  of  the  pyrosis  and  other  symptoms  of  gastralgia,  which 
are  also  quite  frequent  during  pregnancy.  The  treatment  of  the  symptom 
is  here  the  same  as  under  ordinary  circumstances.  Thus,  for  sour  eructations 
and  acidity  of  the  primse  vise,  magnesia  and  the  absorbents,  bicarbonate  of 
soda,  the  water  and  pastilles  of  Vichy,  may  be  administered.  Pyrosis  and 
cramps  of  the  stomach  are  usually  treated  successfully  by  powdered  columbo, 
and  most  of  the  antispasmodics,  in  connection  with  small  doses  of  opiates. 
The  latter  may  also  be  used  after  the  endermic  method. 

If,  however,  it  be  desired  to  attack  the  first  cause  of  these  gastralgic 
symptoms,  it  is  important  to  remember  that  this  is  different  for  the  first 
ind  second  half  of  gestation,  and  that  the  measures  employed  should  vary 
accordingly. 

§  3.  Vomiting. 

The  vomiting  <>f  pregnancy  presents  two  different  forms.  In  the  first,  it 
occasions  discomfort  ami  fatigue,  without  endangering  life.      In  the  second, 


DISEASES    OF    PREGNANCY.  465 

it  is  sometimes  so  severe  as  to  prove  fatal.     The  first  we  shall  term  simple 
vomiting;  the  second,  grave  or  irrepressible  vomiting. 

1.  Simple  Vomiting.  —  This  symptom  is  so  common  that  most  females  are 
affected  with  it;  in  fact,  vomiting  frequently  commences  in  the  very  earliest 
stages:  whence  many  women,  taught  by  their  former  pregnancies,  recognize 
it  as  an  almost  certain  sign  of  a  new  gestation.  At  other  times  it  doe-  not 
appear  until  toward  the  third  or  fourth  month,  though  seldom  later  than 
that ;  but  it  is  not  at  all  uncommon  to  see  it  reappear  near  the  end  of  preg- 
nancy in  some  who  had  been  previously  tormented  in  this  way  at  its  beginning. 
As  an  ordinary  rule,  the  vomiting  only  lasts  six  weeks  or  two  months  ;  some- 
times, however,  it  extends  over  four  or  five  months,  rarely  persisting  through- 
out the  whole  term.  Some  females  have  the  unenviable  privilege  of  vomiting 
every  time  they  are  pregnant ;  others,  more  fortunate,  pass  through  several 
gestations  without  feeling  any  digestive  disorders  whatever.  It  is  a  very 
remarkable  fact,  if  we  may  rely  on  the  testimony  of  numerous  mothers, 
that  the  sex  of  the  child  is  not  wholly  irrelevant  to  the  production  of  this 
symptom  ;  and  however  ridiculous  this  may  appear  at  first  sight,  1  have 
heard  it  repeated  by  so  many  women  that  I  cannot  refrain  from  believing 
that  it,  like  most  other  popular  prejudices,  has  some  foundation. 

But  what  is  the  cause  of  such  vomiting?  When  it  occurs  near  term,  we 
may  justly  attribute  it  to  the  pressure,  to  the  mechanical  constraint  which 
the  uterus,  whose  fundus  reaches  the  epigastric  region,  exercises  upon  the 
stomach  ;  but  in  the  early  stages  it  is  much  more  difficult  to  explain  it  unless 
we  content  ourselves  by  referring  it  to  the  numerous  sympathies  existing 
between  the  uterus  and  the  stomach  :  sympathies  so  intimate  that  they  are 
manifested  in  certain  women  at  every  menstrual  period,  and  even  in  nearly 
all  those  afflicted  with  a  disease  of  the  womb. 

Although  the  intimate  nature  of  these  sympathies  is  very  obscure,  we  can 
admit  them  more  readily  in  the  etiology  of  vomiting  than  the  influence  of 
most  of  the  anatomical  causes  adduced  by  some  authors.  In  endeavoring 
to  trace  a  relation  of  causality  between  the  vomiting  and  an  inflammation 
of  the  uterus,  placenta,  and  membranes,  like  Dance;  softening  of  the  stomach 
and  fatty  degeneration  of  the  liver,  like  Chomel ;  or,  finally,  to  the  existence 
of  organic  lesions  of  parts  in  the  neighborhood  of  the  uterus,  observers  have 
merely  noticed  simple  coincidences,  without  throwing  the  least  light  upon 
the  question  of  etiology.  How  often,  indeed,  is  nothing  of  the  kind  dis- 
coverable ! 

I  am  persuaded,  says  Dr.  Bennett,  that  those  gastric  disorders  and  obsti- 
nate vomitings,  which  so  often  bring  women  to  the  portals  of  the  tomb,  are 
almost  always  caused  by  inflammatory  ulcerations  of  the  neck  of  the  womb. 
For  my  own  part,  he  adds,  since  my  attention  has  been  directed  to  this 
subject,  I  have  almost  invariably  found  ulceration  of  the  neck  in  cases  of 
this  kind. 

1  cannot,  receive  this  opinion  of  the  English  accoucheur,  at  least  as  relat- 
ing to  the  majority  of  cases,  for  I  have  frequently  examined  with  the  specu- 
lum each  of  four  primiparous  women  affected  with  incorrigible  vomiting, 
and  in  whom  I  ascertained  the  cervix  to  be  perfectly  healthy. 

It  has  been  said  that  primiparous  women  are  more  subject  to  vomiting 
xo 


466  PATHOLOGY   OF    PREGNANCY. 

than  others,  on  account  of  the  uterus  }Tielding  less  readily  to  distention  in 
Bret  pregnancies. 

Although  this  opinion  is  quite  conformable  to  the  theoretical  views  al- 
ready given,  the  fact  is,  that  it  is  liable  to  very  frequent  exceptions.  Some 
multipara-,  who  suffered  very  slight  disorders  of  the  stomach  in  their  first 
pregnancies,  have  vomited  almost  constantly  in  later  ones.  The  rigidity 
of  the  uterus  is  not,  therefore,  the  only  cause  which  is  capable  of  sustaining 
an  irritability  of  the  organ  which  reacts  sympathetically  upon  the  stomach. 

I  do  not  think  that  an  epidemic  influence  can  be  admitted  as  a  cause  of 
these  vomitings. 

The  vomiting  varies  much  as  regards  its  frequency,  intensity,  and  the 
greater  or  less  ease  with  which  it  is  accomplished. 

Thus,  some  women  vomit  only  upon  awaking  or  rising  in  the  morning. 
They  then  throw  up  sonic  viscid  or  glairy  matters,  which  are  generally 
colored  with  a  little  bile,  especially  if  the  retchings  have  been  very  severe. 
Others  vomit  only  after  eating;  occasionally  after  only  one  of  the  daily 
meals,  but  sometime-  after  all  of  them.  Again,  in  some  unfortunate  cases 
it  continues  even  in  the  intervals  of  the  repasts  ;  everything  taken  into  the 
6tomach,  whether  liquid  or  solid,  being  immediately  rejected.  There  are 
cases,  finally,  in  which  the  mere  thought  of  food,  or  the  sight  or  smell  of  it, 
is  sufficient  to  provoke  it. 

The  vomiting  is  sometimes  easy,  and  causes  little  pain  ,  it  i-  indeed  not 
uncommon  to  find  ladies  suddenly  interrupted  at  their  meals,  who  can  return 
in  a  few  minutes,  and  sit  down  and  eat  with  a  good  appetite  and  pleasure. 

In  other  cases,  however,  the  ingestion  of  food  is  productive  of  pain  in  the 
6tomach  or  inexpressible  uneasiness  of  variable  duration,  and  it  is  only  after 
five  oi-  six  hours  of  suffering,  that  the  food  is  vomited  and  then  found  to  be 
almost  unchanged,  notwithstanding  its  long  retention  in  the  stomach.  In 
such  cases  the  vomiting  is  preceded  by  such  prolonged  and  violent  retchings 
as  to  reduce  the  patient  to  a  state  of  extreme  suffering  and  agitation. 

It  is  occasionally  followed  by  considerable  epigastric  pain,  which  is  in- 
creased by  pressure,  and  might  for  a  moment  be  taken  as  a  sign  of  inflam- 
mation of  the  stomach  ;  it  gradually  diminishes,  however,  and  disappears 
entirely  after  a  time.  The  shocks  and  violent  efforts  sometimes  extend 
their  influence  to  the  hypogastrium,  and  give  rise  to  abdominal  pains  and 
even  uterine  contractions,  which  maybe  active  enough  to  produce  abortion. 

But  it  must  not  be  supposed  that  vomiting,  even  when  prolonged  and  oft 
repeated,  is  necessarily  disastrous.  No  doubt  many  women  waste  away,  but 
I  have  often  satisfied  myself  that  the  emaciation  is  not  apt  to  be  excessive, 
by  examining  females  who,  according  to  their  own  expression,  could  retain 
nothing  at  all ;  and  hence  it  is  exceedingly  probable  that  all  the  food  taken 
by  them  is  not  rejected. 

Burns  states  that  lie  has  never  known  vomiting  depend  on  pregnancy 
alone  to  have  a  fatal  termination.  I  might  cite,  says  Desormeaux.  examples 
of  emesis  accompanied  by  cruel  pains  and  violent  general  spasms,  yet  the 
gestation  has  happily  gone  on  to  full  term.  At  this  time,  I  have  myself 
under  care  a  lady  who  has  been  vomiting  throughout  the  whole  period  of 
gestation,  and  who  has  just  been  delivered  of  a  daughter  weighing  seven 
pounds  aild  three-quarters. 


DISEASES    OP   PREGNANCY.  467 

Finally,  it  must  not  be  forgotten  that  in  some  cases  which  even  appear 
serious,  the  vomiting  may  cease  abruptly,  either  spontaneously,  or  because 
the  sympathetic  irritation  of  the  uterus  has  been  translated  to  some  other 
organ,  or  again,  as  a  consequence  of  a  violent  mental  emotion.  A  remark- 
able instance  of  the  latter  has  quite  recently  come  under  my  notice.  A 
young  lady,  two  months  and  a  half  advanced  in  her  pregnancy,  had  been 
tormented  for  three  weeks  with  such  obstinate  vomiting,  that,  according  to 
her  own  statement,  the  smallest  mouthful  of  fluid  excited  it,  and  that  she 
was  unable  to  retain  anything  whatever  in  her  stomach.  All  the  remedies 
employed  against  it  had  proved  useless.  At  this  juncture,  her  husband  fell 
suddenly  and  dangerously  ill  with  symptoms  of  strangulation  of  the  bowels, 
and  from  this  time  her  vomiting  ceased,  nor  did  she  suffer  the  least  disturb- 
ance of  her  digestive  functions  afterwards. 

I  have  been  induced  thus  to  hold  forth  from  the  outset  a  favorable  prog- 
nosis, which  indeed  is  true  for  the  vast  majority  of  cases,  in  order  to  relieve 
young  practitioners  from  the  anxiety  which  some  recently  published  articles 
on  the  gravity  of  this  affection  are  calculated  to  produce. 

2.  Grave  or  Irrepressible  Vomiting. — The  vomiting  is  not,  generally, 
serious,  but  only  painful  and  fatiguing  to  the  mother;  it  must,  however,  be 
acknowledged  that  in  some  very  rare  cases,  it  is  so  violent  and  constant  as 
to  exhaust  the  strength  of  the  patient  in  a  few  weeks,  and  after  producing 
extreme  emaciation  terminate  in  death. 

The  display  of  symptoms  given  by  M.  Chomel  in  one  of  his  clinical  les- 
sons, applies  to  these  exceptional  cases  only.  The  disease,  he  says,  is  char- 
acterized by  frequent  bilious  vomiting,  an  acid,  fetid  breath,  and  fever; 
then  the  brain  becomes  involved,  and  we  have  delirium,  coma,  and  death. 

The  views  of  M.  Dubois  correspond  closely  with  those  of  M.  Chomel,  and, 
like  him,  he  describes  three  stages. 

[a.  First  Stage.  —  The  irrepressible  form  of  vomiting  rarely  begins  suddenly,  but 
almost  always  follows  insensibly  the  simple  form.  The  time  at  which  it  commences 
is  very  variable.  Generally  appearing  during  the  early  months,  it  may  not  come 
on  until  after  the  middle  of  gestation.  In  43  cases  collected  in  the  excellent  thesis 
of  M.  Gueniot,  hospital  surgeon,  and  former  chief  of  the  lying-in  hospital,  and  from 
which  we  shall  borrow  largely,  vomiting  occurred  9  times  during  the  first  weeks  of 
pregnancy,  15  times  toward  the  end  of  the  first  month,  9  times  between  the  first 
and  second  months,  5  times  between  the  second  and  third  months,  I  time  between 
the  third  and  fourth  months,  2  times  between  the  fourth  and  fifth  months,  and  2 
times  between  the  sixth  and  seventh  months.  The  first  of  the  cases  enumerated  are 
of  the  early  and  benignant  form,  and  it  is  impossible  to  distinguish  accurately  the 
period  of  transition  from  the  simple  to  the  graver  form. 

The  irrepressible  cases  present  in  themselves  nothing  very  characteristic.  The 
vomiting,  however,  is  very  frequent,  and  occasions  the  rejection  of  all  or  nearly  all 
the  food  and  drink  which  the  patient  takes.  The  smallest  quantity  of  fluid  is  often 
sufficient  to  excite  it. 

The  dejections  in 'these  cases  are  composed  of  mucous  or  glairy  matter,  bile  or 
food,  according  as  the  bowel  happens  to  be  full  or  empty.  Generally  they  are  very 
acid,  and  sometimes  streaked  with  blood. 

To  these  symptoms  may  be  added  a  disgust  for  or  aversion  to  food,  so  great  as  to  be 
often  insurmountable. 

S i   appear   the   grave    signs   of    insufficient    nutrition:    emaciation,   debility,  and 


468  PATHOLOGY    OF    PREGNANCY. 

altered  features.  Certain  accessory  phenomena  may  also  complicate  the  situation 
such  as  tlir  almost  constant  ptyalism  indicated  by  Stoltz  and  Vigla,  and  confirmed 
by  an  observation  of  my  own. 

The  first  stage  is  devoid  of  fever,  unless  it  he  a  little  febrile  action  in  the  even- 
ing and  slight  perspiration  during  the  night.  We  invite  attention  to  this  fact, 
inasmuch  as  fever  is  the  dominant  symptom  in  the  second  stage. 

b.  Second  Stage.  —  In  this  period  the  symptoms  of  the  first  stage  grow  more 
severe;  the  attacks  of  vomiting  are  more  frequent  and  violent;  the  emaciation 
increases  ;  finally,  fever  sets  in  with  a  pulse  of  from  100  to  140  per  minute.  The 
mouth  becomes  dry,  the  thirst  is  intense,  the  breath  acid  and  fetid.  The  acidity 
and  fetidity  of  the  breath  are  such,  says  M.  Chomel,  as  to  strike  one  on  entering 
the  room  of  the  patient.  Still,  should  we  consult  our  personal  experience,  we 
should  say  the  odor  is  uncommon,  inasmuch  as  avo  have  never  observed  it  in  the 
many  cases  of  irrepressible  vomiting  which  we  have  seen. 

c.  Third  Stage.  —  In  this  stage  the  symptoms  undergo  a  change,  the  attacks  of 
vomiting  ceasing  or  becoming  less  severe;  but  it  is  a  deceitful  calm  which  the 
experienced  physician  knows  to  be  the  prelude  to  death.  There  will,  however,  bo 
no  risk  of  deception  if  we  but  observe  that  the  fever  persists  with  a  pusle  of  from 
120  to  140  pulsations  per  minute.  Attacks  of  syncope  and  cerebral  symptoms  soon 
come  on.  These  are:  intolerable  neuralgic  pains,  disordered  sight  and  hearing, 
hallucinations,  delirium,  and,  finally,  coma,  which  ends  shortly  in  death. 

D.  Progress,  Duration,  and  Termination.  —  The  paroxysms  of  the  graver  form  of 
vomiting  often  remit  more  or  less  completely  ;  the  remissions  being  sometimes,  as 
it  were,  spontaneous,  or  in  consequence  of  almost  insignificant  circumstances.  Thus 
an  emotion,  travel,  some  change  in  the  mode  of  life,  a  new  article  of  food,  and 
numerous  similar  eventualities  seem  occasionally  to  produce  a  transient  amelio- 
ration, or  even  a  momentary  cessation  of  the  symptoms.  The  hope  thus  excited  is, 
unfortunately,  hut  too  soon  destroyed  by  a  more  or'  less  rapid  recurrence  of  the 
Jisease.     (Gueniot,  These  de  Concours.) 

At  other  times  these  remissions  may  be  attributed  to  the  use  of  a  remedy  whose 
action  is  exhausted,  or  the  momentary  cessation  may  follow  and  be  due  to  prema 
ture  labor  or  abortion.     Then  the  vomiting  returns  with  increased  severity. 

The  progress  of  this  terrible  affection  is  usually  slow,  as  the  patients  do  not  gen- 
erally succumb  until  after  the  second  or  third  month  of  the  disease. 

e.  Etiology  and  Pathological  Anatomy.  —  We  know  nothing  of  the  causes  of  irre- 
pressible  vomiting.  Some  have  attributed  it  to  albuminuria,  an  opinion  which 
nothing  pics  to  confirm,  and  which  would  hardly  be  adopted  were  it  remembered 
that  vomiting  is  most  frequent  at  the  beginning  or  middle  of  pregnancy,  whilst 
albuminuria  is  rarely  observed  except  during  the  latter  months. 

Of  the  silence  of  pathological  anatomy  in  regard  to  this  disease,  I  have  lately 
had  an  additional  proof. 

A  woman  with  irrepressible  vomiting  entered  my  ward,  at  La  Pitie,  where  I  was 
temporarily  on  duty.  She  was  delivered  spontaneously  during  the  eighth  month, 
but,  after  a  remission,  the  symptoms  reappeared,  and  she  died  a  few  days  subse- 
quently. The  autopsy,  conducted  with  the  greatest  care,  discovered  no  lesion  in 
any  organ  ;  the  genital  organs,  the  abdominal  and  thoracic  viscera,  and  the  3n- 
cephalon,  being  perfectly  healthy.] 

F.  Diagnosis.  —  In  moderate  cases  the  diagnosis  is  easy.  Here,  the 
absence  of  acute  symptoms,  such  as  redness  of  the  tongue  and  pain  upon 
pressure  on  the  epigastrium,  would  settle  the  question,  even  were  pregnancy 
doubtful.  But  if,  in  the  cases  just  spoken  of,  the  nature  of  the  epigastric 
pain  be  misunderstood,  the  practitioner  would  be  more  liable  to  error; 
therefore  he   should   be  very  careful   in   his  proceedings.     For  example,  I 


DISEASES   OF    PREGNANCY. 


469 


have  known  a  case  of  vomiting,  which  the  autopsy  proved  to  have  been 
dependent  upon  tubercular  peritonitis  attributed  to  a  pregnancy  which  did 
not  exist.  In  the  case  of  another  female,  who  had  actually  been  pregnant 
for  two  months  and  a  half,  the  examination  after  death  discovered  a  serious 
disease  of  the  stomach,  amply  sufficient  to  account  for  the  vomiting.  In 
the  latter  case,  it  is  true,  that  an  admixture  of  blood  with  the  matters 
vomited,  had,  during  life,  excited  suspicion  of  organic  disease.  This  very 
case  has,  however,  been  quoted  to  me  by  some  persons  as  one  of  incurable 
vomiting  occasioned  by  pregnancy.  Mistakes  of  this  kind  ought  not  to  be 
made,  and  the  same  may  be  said  in  regard  to  epigastric  and  other  hernias.  ■ 

[g.  Prognosis.  —  The  prognosis  in  the  grave  form  of  this  affection  is  serious. 
In  118  cases  collected  by  M.  Gueniot,  there  were  72  recoveries  and  46  deaths,  repre- 
sented as  follows : 

Recoveries. 
Without  abortion  in  very  severe  cases  and  after  a  very  diversified  treatment...   31 

Following  spontaneous  abortion,  also  in  very  severe  cases 20 

After  aborcion  or  induced  labor  in  cases  more  or  less  desperate 21 

Deaths. 

OS 

Without  abortion m 

After  abortion  or  spontaneous  premature  labor ' 

After  procured  abortion 

It  is  but  just  to  say,  that  in  this  table  of  mortality,  M.  Gueniot  included  all  the 
cases  he  was  able  to  collect,  and  that  amongst  them  are  some  in  whicli  death  was 
evidently  due  to  some  other  disease  than  the  vomiting  itself. 

Cases  of  irrepressible  vomiting  are  serious  from  the  outset,  inasmuch  as,  notwith- 
standing all  the  modes  of  treatment  employed,  abortion  included,  it  is  impossible 
to  know  whether  they  will  be  certainly  arrested. 

The  prognosis  becomes  still  more  unfavorable  in  the  second  stage  of  the  disorder, 
for  when  the  patients  are  much  debilitated  and  the  fever  constant,  some  will  suc- 
cumb without  having  either  the  fetid  breath  or  cerebral  disorders.  Of  such  cases, 
two  have  come  under  my  notice. 

In  the  last  stage,  death  is  almost  inevitable,  and  we  ought  not  to  be  deceived  by 
the  remission  of  vomiting  which  then  occurs.  It  should  also  be  borne  in  mind  that 
the  cerebral  symptoms  which  accompany  this  phase  of  the  disease  are  various.  In 
two  cases,  I  observed  only  a  little  hebetude  and  slight  strabismus  without  other 
nervous  disturbance:  so  that,  before  reaching  the  correct  diagnosis,  typhoid  fever, 
or  a  cerebral  tumor  might  be  suspected.] 

Generally  speaking,  even  when  the  vomiting  is  not  so  great  as  to  com- 
promise the  life  and  health  of  the  mother,  it  has  but  an  indirect  influence 
upon  the  life  of  the  child,  nor  do  I  know  of  a  single  well-attested  case  of 
death  of  the  foetus  from  inanition  through  defective  nutrition  of  the  mother. 

Still,  we  may  understand  how  the  violent  efforts  of  the  mother  may  some- 
times communicate  such  shocks  to  the  uterus  as  to  bring  on  premature  con- 
tractions and  even  abortion.  We  can  also  comprehend  how  the  same  efforts 
may  produce  vascular  congestion  of  the  womb,  giving  rise  to  rupture  of 
some  of  the  utero-placental  vessels  and  detachment  of  the  placenta;  such 
accidents  are,  however,  rare.  In  grave  cases,  results  of  the  kind  are  rather 
to  be  desired  than  deprecated,  for  vomiting  generally  erases  upon  the  death 
of  the  foetus,  and  the  mother  escapes  the  threatened  danger. 


-170  PATHOLOGY    OF    PREGNANCY. 

3.  Treatment  of  the  Vomiting  of  Pregnancy.  —  There  are  but  few  medi- 
cines that  have  not  been  proposed,  at  one  time  or  another,  for  this  affection 
of  pregnant  women  ;  and  at  other  times  recourse  has  been  had  to  surgical 
procedures.  We  will,  therefore,  examine  successively  the  medical  and  sur- 
gical treatment. 

A.  Medical  Treatment.  —  "When  the  emesis  is  slight,  and  only  occurring 
in  the  morning,  we  may  recommend  an  aromatic  infusion  of  the  lime-tree, 
orangd-ilower,  common  tea,  &c  ,  &c.  Where  it  comes  on  after  a  meal  during 
the  day,  it  is  advisable  to  change  the  order  of  the  repasts:  for  example,  if 
it  be  generally  more  distressing  after  supper,  the  patient  should  sup 
sparingly  and  eat  more  breakfast.  Cold  aliments  are  sometimes  retained 
when  others  are  rejected.  Iced  drinks,  mineral  waters,  and  swallowing 
small  pieces  of  ice,  have  arrested  some  cases  of  obstinate  vomiting,  which  set 
at  defiance  the  whole  series  of  antispasmodics.  The  subnitrate  of  bismuth, 
in  doses  of  from  four  to  eight  grains,  hefore  each  meal,  has  appeared  to  me 
of  late  to  be  of  some  service.  I  have  also  directed  two  or  three  spoonfuls 
of  kirsch  to  be  taken  after  meals,  and  1  think  with  some  success.  Should 
it  persist,  notwithstanding  these  measures,  a  resort  maybe  had  to  a  remedy, 
which  has  often  succeeded  perfectly  in  my  hands,  —  I  allude  to  the  narcotics. 
About  an  hour  before  the  meal,  let  her  take  one-third  or  one-half  a  grain 
of  the  aqueous  extract  of  opium  made  into  a  pill  ;  but  when  she  is  consti- 
pated, it  will  be  necessary  to  administer  some  mild  purgative  to  counteract 
any  action  the  opium  may  have  on  the  large  intestine. 

Whenever  the  emesis  is  attended  with  pain  and  stricture  at  the  epigas- 
trium, leeches  have  been  recommended  over  this  part,  though  I  have  rarely 
seen  their  application  followed  by  any  benefit.  I  should  prefer  laudanum 
lotions,  or  the  application  of  a  cataplasm  well  tinctured  with  this  fluid. 
Sometimes  I  have  successfully  applied  a  small  blister  to  the  epigastrium, 
and  subsequently  sprinkled  the  sixth  or  the  third  of  a  grain  of  the  muriate 
or  acetate  of  morphia  over  it. 

M.  Dezon  mentions  three  cases  of  obstinate  vomiting,  which  yielded  to 
the  continued  application  to  the  epigastrium  of  a  towel  wet  with  cold  water 
and  renewed  every  five  minutes. 

If  the  vomiting  occasions  pains  in  the  loins  or  hypogastrium,  in  a  word, 
if  it  threatens  an  abortion,  or  if  the  patient  be  plethoric,  and  this  condition 
is  manifested  by  local  or  general  phenomena,  venesection  in  the  arm  should 
be  resorted  to,  as  this  is  one  of  the  best  measures  I  am  acquainted  with, 
especially  during  the  last  half  of  gestation.  Enemata  containing  laudanum 
are  also  very  useful  for  the  prevention  of  abortion,  as  well  as  for  alleviating 
the  vomiting,  and  calming  the  irritability  of  the  uterus.  General  bathing 
may  be  added  to  these  measures  with  advantage. 

Dance  reports  two  cases,  from  which  he  feels  authorized  to  conclude  that 
these  vomitings  are  often  an  evidence  of  a  morbid  activity  in  the  uterine 
system,  of  an  inflammation  of  the  membranes;  and  consequently  he  advises 
direct  antiphlogistic  measures,  especially  in  the  neighborhood  of  the  womb; 
but  as  his  opinion  i~  founded  on  two  cases  only,  which,  after  all,  arc  not 
conclusive,  it  seems  to  me  that  it  cannot  be  admitted  as  a  rule  of  practice. 
Still,  leeching  the  nek  of  the  uterus  yielded  unlooked-for  results  in  cases  of 
fih.  Clay  and  M.  Clertan  (of  Dijon)'. 


DISEASES     OF     PREGNANCY.  471 

With  regard  to  the  regimen,  doubtless  a  mild  liquid  diet,  composed  of 
aliments  that  are  easily  digested,  seems  at  first  to  possess  decided  advan- 
tages over  all  others  ;  "but  how  many  exceptions !  how  many  women  reject 
the  mildest  articles  —  even  liquids,  and  yet  readily  digest  less  suitable  sub 
stances !  How  often,  indeed,  have  I  not  seen  women  eat  ham,  liver,  pie 
&c,  who  could  not  digest  a  piece  of  sole,  or  the  white  meat  of  fcwl !  Of 
course,  we  must  respect  these  peculiarities  of  the  stomach. 

Among  the  various  measures  recommended,  but  which  I  have  rarely  had 
occasion  to  resort  to,  may  be  mentioned  the  application  of  cups  to  the  pit 
of  the  stomach  (Mauriceau) ;  of  a  plaster  of  theriaca  (Sydenham)  ;  a  few 
spoonfuls  of  sherry-wine,  or  even  some  brandy,  ether,  peppermint-water,  the 
potion  of  Riviere,  and  the  Colombo  root. 

In  those  cases  in  which  there  was  some  degree  of  regularity  in  the  return 
of  the  pains,  and  febrile  action,  Desormeaux  gave  two  or  three  grains  of 
the  dry  extract  of  cinchona  with  success.  '  Lastly,  Walter  and  Blundell 
have  highly  extolled  the  use  of  hydrocyanic  acid  in  the  dose  of  one  or  two 
drops,  in  some  mucilaginous  drink,  several  times  a  day.  With  the  same 
idea,  I  have  successfully  given  kirsch  after  meals,  either  undiluted  or  on  a 
lump  of  sugar.  The  latter  plan  has  seemed  especially  useful  when  the 
vomiting  was  preceded  by  uncomfortable  sensations  in  the  stomach  or  long- 
continued  nausea — a  state  of  things  resembling  sea-sickness. 

To  overcome  the  acidity  of  the  primse  vise,  M.  Chomel  recommends  the 
use  of  alkalies,  as  the  water  from  the  springs  of  Vichy  and  Bussang ;  also 
dilute  solutions  of  potash  and  soda,  magnesia  with  milk,  but  never  milk 
alone,  and  an  avoidance  of  acids. 

Alcoholic  liquors,  given  to  the  extent  of  intoxication,  have  met  with  real 
success.  M.  Bayer  tells  me  that  he  has  used  them  with  great  advantage, 
and  champagne  wine,  recommended  by  M.  Moreau  in  a  case  so  obstinate  as 
to  cause  great  frequency  of  pulse  and  delirium,  put  an  end  at  once  to  the 
symptoms.  M.  Jacquemin,  who  related  the  case  to  me,  considered  the  pa- 
tient as  lost,  and  had  only  called  the  professor  in  consultation,  in  order  to 
obtain  his  opinion  in  regard  to  the  propriety  of  producing  abortion. 

M.  Bretonneau,  being  induced  to  try  belladonna,  in  the  idea  that  possibly 
the  vomiting  might  be  occasioned  by  rigidity  of  the  uterus,  succeeded  in 
quieting  it,  even  in  very  grave  cases,  by  rubbing  the  abdomen  with  a 
concentrated  solution  of  that  medicament. 

In  one  very  serious  case,  in  which  the  vomiting  had  resisted  every  effort, 
even  Bretonneau's  measure,  and  in  which  the  poor  patient  seemed  doomed 
to  a  speedy  death,  I  conceived  the  idea  of  applying  the  belladonna  to  the 
neck  of  the  uterus;  this  was  done  by  means  of  the  speculum.  A  brush, 
laden  with  the  soft  extract,  was  introduced,  and  the  neck,  together  with 
the  inferior  segment  of  the  uterus  and  the  walls  of  the  vagina,  were  be- 
smeared with  it.  From  this  moment,  a  marked  change  lor  the  heller  was 
manifest,  and  after  the  same  unctions  had  been  repeated  on  four  successive 
days,  I  had  the  satisfaction  of  finding  my  patient  cured.  It  is  my  duty  to 
add,  that  in  another  case  the  same  means  failed  completely,  though  I  think 
the  failure  due  to  the  mode  of  application.  When,  as  in  this  case,  a  brush 
is  used,  it  is  difficult  to  apply  the  ointment,  and  too  little  of  it  is  sometimes 


472  PATHOLOGY  OF  PREGNANCY. 

left  behind.  I  have,  therefore,  for  a  long  time  preferred  covering  a  tampon 
of  charpie  or  cotton  with  the  extract  of  belladonna,  and,  after  placing  it  in 
contact  with  the  cervix  by  means  of  a  speculum,  leaving  it  there.  This 
may  be  done  morning  and  evening.  The  first  symptoms  of  intoxication, 
such  as  dilatation  of  the  eyelids,  a  sense  of  heat  in  the  throat  and  slight 
hallucinations,  need  occasion  no  alarm,  inasmuch  as  the  effects  of  the  medi- 
cament are  not  felt  until  then.  The  patient  ought,  however,  to  be  watched, 
and  the  tampon  removed  if  the  symptoms  become  more  serious.  This 
method  has  been  thrice  successful  in  my  hands. 

M.  Stockier  overcame  the  vomiting  in  two  cases  by  the  black  oxide  of 
mercury,  in  the  dose  of  one  grain  daily.  The  prolonged  use  of  the  remedy 
was  unaccompanied  by  salivation. 

[Iodine  in  various  forms  lias  been  recommended.  Eulenberg  (of  Coblenz),  fol- 
lowing the  example  of  Schmidt,  has  used  the  tincture  successfully,  whilst  Ricord 
and  Bacarisse  derived  equal  advantage  from  iodide  of  potassium  given  to  the 
amount  of  from  ten  to  fifteen  grains  daily. 

"Simpson,"  say-  M.  Gueniot,  "found  the  salts  of  cerium  very  efficacious,  especially 
the  oxalate,  in  5-grain  doses  three  or  tour  times  a  day.  I  would  add  that  the  latter  sail 
failed  entirely  in  a  case  related  by  M.  Danyau,  in  which  it  was  used  by  him  and  M. 
Dubois,  nothing  short  of  a  partial  detachment  of  the  ovum  sufficing  to  relieve  the 
patient  from  the  danger  which  menaced  her." 

Copeman  recommends  dilatation  of  the  os  externum  and  cervical  canal  with  the  index 
finger,  a  method  which  has  received  the  indorsement  of  Dr.  Marion  Sims. 

Dr.  •  rraily  Hewitt  recommends  appropriate  mechanical  support  to  the  womb,  regard- 
ing the  vomiting  of  pregnancy  as  due  to  displacements  of  thai  organ. 

Dr.Jacob  Price,  in  an  address  before  the  Penn.  State  Med.  Society,  May,  1884,  advo- 
cated the  application,  at  intervals  of  three  days,  of  a  solution  of  Iodine,  Carbolic  Acid, 
and  Tannin,  each  two  drachms,  dissolved  by  heat  in  an  ounce  of  Glycerine.  He 
regards  the  pernicious  vomiting  of  pregnancy  as  due  to  congestion  and  inflammation  of 
the  uterine  cervix.] 

The  obstinate  constipation  which  the  patients  suffer  is  very  remarkable, 
and  has  not  received  the  attention  it  deserves.  The  bowels  sometimes  re- 
main unmoved  for  eight,  ten,  or  even  fifteen  days.  Strongly  impressed  with 
this  fact,  and  supposing  that  the  constipation  might  have  some  effect  upon 
the  continuance  of  the  vomiting,  I  endeavored  to  overcome  it;  but,  fearing 
the  effect  of  emetics  or  drastic  purgatives  upon  a  weakened  and  pregnant 
female,  my  first  efforts  were  too  cautious  to  be  successful.  Encouraged 
since  then  by  the  experience  of  other  practitioners,  especially  by  M.  Forgue, 
of  Etampes,  I  have  had  every  reason  to  be  satisfied  with  a  bolder  course. 

The  above-named  physician  addressed  to  the  Academy  of  Medicine  a 
memoir,  in  which  he  hauled  the  effect  of  emetics  and  purgatives,  but  in- 
sisted much  upon  what  he  called  a  preparatory  treatment,  consisting  in  the 
administration  to  the  patient  for  two  or  three  days,  a  ptisan  of  barley-water, 
weakened  with  homy,  to  each  quart  of  which  he  adds  a  drachm  and  a  half 
of  Bulphate  of  potash  ;  giving  also,  morning  and  evening,  an  enema  of  a 
strong  decoction  of  mercurialis  annua.  When  some  stools  have  been  thus 
obtained,  he  orders  a  bottle  of  Seidlitz  water  containing  a  grain  and  a  half 
of  tartar  emetic,  alter  which  he  continues  the  purgative  for  several  days 
longer.  M.  Forgue  claims  to  have  treated  five  cases  successfully  by  his 
method. 


DISEASES   OF    PREGNANCY. 


473 


[am  in  the  habit  of  giving  the  emetic  at  once,  when  the  sabnrral  condition 
<»  the  tongue  seems  to  indicate  it :  which  is  nut  often  the  case.  Generally,  1 
order  at  once  ten  grains  of  scammony  with  fifteen  .-rains  of  jalap.  As  the 
firsl  dose  is  often  rejected  by  vomiting,  I  order  it  to  ho  followed  immediately 
by  another,  and  sometimes  even  by  a  third,  should  the  vomiting  continue. 

*  The  ser  ond  or  third  dose  is  generally  retained,  and  the  purgative  cFect 
followed  bv  a  marked  relief. 

In  the  case  of  a  patient  two  months  and  a  half  advanced  in  pregnancy, 
to  whom  I  was  called  in  consultation  by  Dr.  Briau,  Professor  Moreau  dis- 
covered by  the  touch  that  the  uterus  was  not  only  completely  retroverted, 
but  wedged,  as  it  were,  in  the  depths  of  the  pelvic  cavity.  Suspecting  that 
this  displacement  might  have  some  effect  to  maintain  the  vomiting,  he  cor- 
rected it  by  lifting  the  uterus  above  the  superior  strait  and  bringing  it  into 
correspondence  with  its  axis.  Immediate  relief  followed,  and  the  vomiting, 
which  had  proved  intractable  to  a  host  of  remedies,  ceased  on  the  same  day, 
nor  rtid  it  again  return.  _ 

M.  Moreau  said,  that  he  had  seen  several  similar  cases.  I  had  indeed 
myself,  before  this,  observed  the  same  accident,  but  not  having  acted  upon 
the  indication,  our  Honorable  master  conferred  a  real  service  in  making 
known  the  fortunate  result  which  he  had  thus  obtained. 

In  future,  therefore,  the  state  of  the  uterus  should  be  ascertained  in  all 
cases  of  incorrigible  vomiting.  Experience  has,  however,  taught  me,  that 
although  displacement  of  the  uterus  often  coincides  with  gastric  disorder, 
M.  Moreau's  good  fortune  is  not  always  to  be  expected.  Three  times  since 
M.  Briau's  case  have  I  observed  the  coincidence  indicated  by  my  colleague. 
In  three  patients  suffering  from  obstinate  vomiting,  I  found  the  uterus  not 
retroverted,  as  in  M.  Moreau's  case,  but  so  far  anteverted  that  the  anterior 
surface  of  the  womb  projected  considerably  at  the  upper  part  of  the  cavity, 
its  upper  border  resting  against  the  posterior  face  of  the  pubis.  The  reduc- 
tion, though  easily  accomplished,  could  not  be  maintained,  and  the  organ 
very  soon  resumed  its  primitive  position.  Several  attempts  at  reduction 
were  equally  unsuccessful. 

Why,  then,  was  I  less  fortunate  than  M.  Moreau  ?  I  am  inclined  to  think 
it  was  because  of  the  different  stages  of  pregnancy  in  our  patients  respec- 
tively. That  of  M.  Moreau  had  reached  three  months  or  three  months  and 
a  half;  two  of  mine  were  only  two  months  gone.  Now,  if  at  three  months 
and  a  half  the  size  of  the  uterus  is  sufficient  to  keep  it  above  the  superior 
strait  after  reduction,  and  that  it  can  only,  in  some  exceptional  instances, 
fall  back  into  the  cavity,  the  case  is  very  different  at  an  earlier  period.  At 
two  months,  in  fact,  the  uterus  is  so  much  smaller,  and  therefore  so  much 
more  movable,  that  it  yields  readily  to  every  cause  of  displacement  brought 
to  bear  upon  it,  and,  as  though  by  the  force  of  a  bad  habit,  readily  resumes 
its  faulty  position  when  the  restoring  effort  is  no  longer  made. 

We  ought,  therefore,  in  reference  to  M.  Moreau's  plan,  to  have  great 
regard  to  the  duration  of  the  pregnancy ;  very  efficient  after  the  third 
month,  it  will  generally  be  useless  at  six  weeks  or  two  months.  Unfor- 
tunately it  happens  that  incorrigible  vomiting  is  more  apt  to  occur  at  the 
latter  period. 


474  PATHOLOGY    OF    PREGNANCY. 

All  my  eff<  rts  to  remedy  the  difficulty  by  means  devised  for  keeping  die 
uterus  in  situ  after  reduction,  have  been  fruitless.  I  had  made  an  elongated 
compress,  which,  when  placed  above  tbe  pubis,  depressed  strongly  the  wal: 
of  the  hypogastrium,  and  at  first  seemed  to  keep  the  womb  in  place.  Soon 
however,  it  slipped  beneath  the  pad,  fell  back  into  the  pelvic  cavity,  and 
as  the  bandage  thenceforth  did  more  harm  than  good,  I  was  obliged  to  give 
it  up. 

It  was  natural  to  think  of  Gariel's  pessary,  but  I  dared  not  keep  so  laige 
a  body  in  the  vagina  of  a  pregnant  woman,  lest  it  should  have  the  effect  on 
the  uterus  of  a  tampon  which  so  often  causes  abortion  or  brings  on  prerna*- 
ture  labor. 

In  short,  M.  Moreau's  success  in  the  case  related  by  M.  Briau,  is  an  en- 
couragement to  make  similar  attempts,  as,  after  all,  they  do  no  harm  when 
prudently  conducted  ;  yet,  they  are  not  to  be  relied  on  when  the  patient  has 
nut  advanced  beyond  the  first  two  months  of  pregnancy. 

I  have  thus  enumerated  all  these  remedies,  because  they  may  be  succes- 
sively employed  in  this  affection.  In  fact,  the  same  medicine  may  act  on 
one  female  and  have  no  effect  on  another.  And  it  must  be  confessed  that 
sometimes  all  will  fail,  and  we  can  scarcely  succeed  in  moderating  the 
patient's  sufferings.  The  change  of  medicine  is,  however,  useful,  either  by 
really  calming  her  distress  in  a  measure,  or  by  sustaining  her  spirits,  not 
seeming  to  abandon  her,  but  holding  out  the  idea  that  each  new  remedy 
may  effect  some  amelioration.  In  this  way  she  gradually  approaches 
towards  term,  or  at  least  to  a  period  of  gestation  when  the  symptoms  often 
disappear  of  themselves. 

B.  Surgical  Treatment. — But  where  the  vomitings  continue,  notwithstand- 
ing all  the  rational  measures  resorted  to,  the  woman  absolutely  throwing 
up  everything  she  takes,  and  the  privation  from  food  has  reduced  her  tu 
such  a  state  of  emaciation  as  to  endanger  life,  and  the  symptoms  which  we 
have  described  as  belonging  to  the  second  ami  third  stages  appear,  some 
accoucheurs  have  advised  (if  her  term  is  still  remote)  the  production  of 
premature  labor.  This  operation  has  already  been  practised,  in  similar 
cases,  by  several  English  and  .German  accoucheurs,  with  full  success,  both 
for  the  mother  and  child. 

It  seems  to  me  that  it  cannot  be  improper  to  resort  to  this  measure  after 
the  seventh  month  of  gestation,  for  it  then  appears  to  be  fully  justified  both 
by  the  dangers  to  which  the  mother  is  exposed,  and  by  the  possibility  of  the 
child  living  after  its  expulsion. 

But  is  the  case  the  same  before  the  sixth  month,  when  the  sudden  termina- 
tion of  pregnancy  must  necessarily  lead  to  the  death  of  the  foetus.  This  is 
one  of  the  gravest  questions  which  can  come  up  in  practice.  Although 
fully  disposed  to  sacrifice  the  child  whenever  that  sacrifice  will  surely  save 
th*»  life  of  the  mother,  as  m  cases  of  extreme  narrowing  of  the  pelvis,  I 
make  no  hesitation  in  declaring  myself  against  the  production  of  abortion 
under  the  circumstances  in  question. 

I  shall  proceed  to  justify  this  proscription  :  — 

1.  When  a  woman  having  a  contracted  pelvis  presents  herself  to  a  physi- 
cian, he  knows  very  well  that  if  the  pregnancy  be  allowed  to  go  on  until 


DISEASES    OF    PREGNANCY.  475 

term,  he  will  have  to  choose  between  embryotomy  and  the  Cesarean  opera- 
tion ;  also,  that  in  some  cases  the  latter  operation  will  be  the  only  resource. 
If,  after  mature  consideration  of  the  inevitable  consequences  of  the  one  and 
the  probable  consequences  of  the  other,  he  decides  upon  the  mutilation  of 
the  child,  it  will  doubtless  appear  to  him  reasonable  not  to  wait  until  the 
increased  size  of  the  foetus  at  term  shall  add  to  the  difficulties  and  dangers 
of  embryotomy ;  therefore,  the  production  of  abortion  within  the  first  fuur 
months  of  gestation  will  seem  to  be  fully  justifiable. 

But  the  conditions  are  different  when  the  life  of  the  mother  is  compro- 
mised by  vomiting,  however  severe  it  may  be. 

In  the  first  case,  the  danger  is  inevitable  ;  and,  unless  abortion  occurs 
spontaneously,  the  Csesarean  operation  is  the  only  resource,  and  we  are 
aware  of  the  usual  consequence  of  the  latter.  But  however  intense  the 
vomitings  may  be,  and  notwithstanding  the  state  of  exhaustion  to  which 
they  reduce  the  female,  still  they  are  not  inevitably  fatal.  Patients,  whose 
condition  justly  excited  the  greatest  solicitude,  have  been  known  to  resist 
until  the  latter  months  and  even  until  the  term  of  their  pregnancy,  and 
then  give  birth  to  strong  and  healthy  children.  Others,  whom  the  vomiting 
had  reduced  to  a  hopeless  condition,  have  been  suddenly  restored  to  the 
most  complete  health.  A  case  of  this  kind  has  fallen  under  my  own  notice, 
and  the  following  was  related  to  me  (June,  1849)  by  M.  P.  Dubois. 

A  young  German  lady,  two  months  and  a  half  pregnant,  had  been  troubled 
with  the  most  obstinate  vomiting  from  the  first  two  weeks  after  conception. 
For  the  last  six  weeks  especially  she  vomited  almost  without  intermission ; 
the  smallest  spoonful  of  fluid  exciting  violent  contractions  of  the  stomach. 
She  was  extremely  emaciated  and  feeble,  and  her  breath  was  disgustingly 
fetid  ;  in  short,  her  symptoms  were  so  serious  that  M.  Dubois,  who  was  called 
in  consultation,  requested  the  additional  advice  of  M.  Chomel.  Both 
these  gentlemen  came  to  a  most  unfavorable  prognosis,  and  left  the  patient, 
under  the  impression  that  she  had  but  a  few  days  to  live.  Some  cold  appli- 
cations were  the  only  remedies  advised  ;  but  the  attending  physician,  being 
alarmed  at  her  extreme  weakness,  limited  them  to  slight  aspersions.  On 
the  second  day  after  the  consultation  the  patient  was  attacked  with  violent 
purging,  and  from  that  time  the  vomiting  ceased  and  never  returned.  The 
poor  sufferer  was  at  once  able  to  take  and  retain  some  nourishment,  which, 
being  gradually  increased  in  amount,  soon  restored  her  strength.  Now, 
this  woman,  who  had  been  so  greatly  reduced  that  two  eminent  men  regarded 
her  fate  as  sealed,  is  in  the  enjoyment  of  perfect  health,  and  has  almost 
reached  the  middle  of  her  pregnancy  with  every  prospect  of  a  happy  ter- 
mination. 

In  two  other  cases,  which  the  professor  related  with  commendable  frank- 
ness, he  had  deemed  it  his  duty  to  propose  the  induction  of  premature  labor. 
The  women  declined  submitting  to  the  operation,  and  reached  the  end  of 
their  pregnancies  in  good  health. 

2.  When  abortion  is  produced  in  cases  of  extreme  contraction  of  the 
pelvis,  there  is  a  certainty  that,  when  once  accomplished,  all  the  dangers 
which  threatened  the  termination  of  the  pregnancy  are  at  an  end,  and  that 
only  the  usual  consequences  of  miscarriages  can  follow  from  the  operation. 


476  PATHOLOGY   OF   PREGNANCY. 

Even  suppoiing  that  the  artificial  means  should  add  to  the  ordinary  risks 
of  spontaneous  abortions,  the  object  is  nevertheless  certainly  attained  in  ter» 
ruinating  a  pregnancy  whose  progress  so  greatly  endangered  the  mother's  life. 

The  conditions  are  very  different  in  cases  of  spontaneous  vomiting,  for  if 
all  the  instances  on  record  be  referred  to,  it  will  be  found  that  the  operation 
ip  far  from  removing  the  danger.  I  am  well  aware  that  four  or  five  for- 
tunate cases  have  been  cited  from  the  practice  of  English  accoucheurs,  but 
we  are  not  told  how  often  it  has  been  followed  by  death. 

Are  the  circumstances  the  same  in  cases  of  obstinate  vomiting?  If  un- 
successful, the  operation  was  performed  too  late,  say  they,  when  the  pro- 
longed defective  nutrition  of  the  mother  had  exhausted  the  vital  powers ; 
and  had  the  uterus  been  emptied  sooner,  the  chances  of  success  had  cer- 
tainly been  greater. 

I  believe  this  fully  ;  but  here  it  is  that  the  most  difficult  question  arises. 
When  is  the  operation  proper  ?  If  you  act  too  soon,  may  it  not  be  said, 
whilst  instancing  the  cases  of  spontaneous  cessation  of  the  vomiting,  as  in 
those  which  have  been  quoted,  that  you  have  destroyed  the  foetus  without 
advantage?  If  you  act  too  late,  may  you  not  be  equally  reproached,  in 
view  of  the  failure  of  all  known  operations,  with  an  attempt  which  may 
have  hastened  the  fatal  termination  ? 

Where  will  the  prudent  practitioner  place  the  limit  of  expectancy?  If 
it  be  remembered  that  the  ancient  accoucheurs  declared,  as  do  Mauriceau 
and  Delamotte,  that  the  vomitings  may  possibly  produce  abortion,  yet  are 
not  dangerous  for  the  mother;  also  that  many  moderns  assert,  with  Burns 
and  Desormeaux,  that  they  have  never  known  them  to  terminate  fatally, 
there  would  certainly  be  small  temptation  to  operate  before  all  hope  has 
been  dissipated  by  the  gravity  of  the  symptoms.  Our  hopes,  indeed  !  But 
does  not  nature  sometimes  mock  at  our  expectations?  Did  not  the  patient 
of  MM.  Dubois  and  Chomel  seem  doomed  to  certain  death  ? 

I  know  it  may  be  answered  that  it  must  be  left  to  the  tact  and  skill  of 
the  practitioner  to  think  deeply,  and  choose  conscientiously  between  the 
dangers  of  expectation  and  the  chances  of  an  operation ;  that  the  difficulties 
which  I  raise,  present  in  a  host  of  surgical  cases;  that  there  is  barely  an 
amputation  which  may  not  be  authorized  by  affirming,  dogmatically,  that  a 
spontaneous  cure  is  impossible ;  that  the  exceptional  preservation  of  a  limb 
proves  nothing  against  the  propriety  of  amputation  in  a  majority  of  similar 
cases. 

All  this  is  doubtless  true;  but  let  us  not  decide  too  quickly,  for  the  com- 
parison is  far  from  being  strictly  just. 

When  the  surgeon  has  to  deal  with  a  serious  traumatic  lesion,  he  regards 
nothing  but  the  interest  of  his  patient;  and  after  explaining  to  him  the 
grounds  of  his  conclusion,  may,  in  cases  of  difficulty,  consult  his  wishes,  and 
then  leave  his  life  at  his  own  disposal.  The  accoucheur  has  the  serious 
interest  of  two  beings  to  care  for;  and  though  the  instinct  of  self-preser- 
vation may  silence  in  the  female  the  voice  of  maternal  feeling,  it  is  never- 
theless his  duty  to  protect  the  foetus,  with  whose  welfare  he  is  equally 
intrusted. 

In  a  given  traumatic  lesion,  all  experience  shows  that  spontaneous  recovery 


DISEASES    OF   PREGNANCY. 


477 


is  a  rare  exception.  On  the  other  hand,  the  experience  of  all  accoucheurs 
goes  to  pn-ve  that  the  spontaneous  cessation  of  vomiting  is  of  almost  uni- 
versal occurrence. 

Dubois  met  with  20  fatal  cases  of  intractable  vomiting  in  13  years.  Tyler 
Smith  mentions  two  cases  that  died  before  abortion  could  be  induced  (  Leish- 
man'8  System  of  Midwifery). 

[We  shall  proceed  no  further  with  this  discussion,  but  first  of  all  examine  the 
facts.  Experience  having  shown  that  abortion  and  spontaneous  labor  were,  in 
cases  of  obstinate  vomiting,  often  followed  by  recovery,  it  was  naturally  asked  by 
physicians  whether  the  process  adopted  by  nature  might  not  properly  be  effected 
by  art.  Some  trials  having  been  made  here  and  there,  M.  Denieux  succeeded  in 
collecting  32  of  them,  which  he  quotes  in  his  thesis,  giving  as  a  result  21  recoveries 
and  11  deaths.  Of  the  21  successful  cases,  15  were  abortions,  and  6  premature 
labors.  To  these  we  would  add  a  case  of  our  own,  in  which  the  vomiting  being 
severe,  and  death  imminent,  it  was  decided,  in  consultation  with  Dre.  Millard  and 
Charrier,  that  abortion  should  be  produced.  The  operation  was  successful.  It  was 
a  twin  pregnancy  of  two  months  duration. 

Our  conclusion  is,  that  procured  abortion,  as  well  as  premature  delivery,  is  a 
valuable  resource  in  intractable  vomiting.  It  is  nevertheless  true  that  it  has  the 
great  disadvantage  of  certainly  sacrificing  the  life  of  the  child  ;  therefore,  before 
undertaking  the  operation,  the  conviction  derived  from  mature  consideration  that 
no  other  course  remains  by  which  the  mother's  life  can  be  saved,  should  be  sus- 
tained by  the  concurrence  of  several  medical  friends  in  consultation. 

It  is,  in  fact,  more  difficult  under  these  circumstances  than  in  a  case  of  extreme 
contraction  of  the  pelvis  to  determine  the  propriety  of  producing  abortion,  and  that, 
too,  without  having  the  same  certainty  of  saving  the  patient.  We  shall  not  revert 
to  the  comparison  of  such  cases,  already  made  on  page  474. 

Another  difficult  question  remains  to  be  settled :  At  what  time  ought  abortion 
to  be  effected?  In  reply,  we  can  do  no  better  than  quote  the  opinion  of  P.  Dubois. 
"  The  production  of  abortion  in  the  third  stage  of  the  disease  is  liable  to  the  grave 
objection  of  not  saving  the  patients,  but  of  hastening  their  end  and  compromising 
our  art.  If  done  in  the  first  stage,  there  would  be  the  not  less  serious  error  of 
sacrificing  a  pregnancy  which  might,  perhaps,  have  progressed  happily  to  its  term. 
Therefore,  we  conclude  that  the  operation  is  applicable  to  the  period  intermediate 
to  those  mentioned."  We  would  here  call  to  mind  that  this  second  period  is 
characterized:  1,  by  almost  incessant  vomiting,  produced  by  all  kinds  of  food,  and 
sometimes,  also,  by  the  least  quantity  of  pure  water;  2,  by  debility  so  great  as  to 
keep  the  patient  at  rest,  and  occasionally  by  syncope  ;  3,  continued  fever;  4,  in 
certain  cases  by  a  fetid  and  even  putrid  breath.  When  to  these  symptoms  is  added 
the  failure  of  all  the  medication  which  has  been  tried,  it  is  right  to  advise  abortion, 
leaving  with  the  family  the  responsibility  of  deciding  upon  it  as  a  last  resort. 

Different  operative  procedures  may  be  employed,  the  comparative  value  of  which 
will  come  under  discussion  hereafter.     (See  Operations.)] 

§  4.  Constipation.     Diarrhoea. 

Constipation  is  a  very  common  affection  in  pregnant  women,  and  it  is 
usually  attributed  to  the  pressure  of  the  developed  uterus  on  the  upper  part 
of  the  rectum,  by  which  not  only  the  calibre  is  diminished,  but  its  action  is 
also  paralyzed.  Would  it  not  be  more  reasonable  to  attribute  it  in  many 
cases  to  a  commencing  chlorosis?  We  know,  indeed,  that  constipation  is  - 
common  in  the  Latter  disease  that  Hamilton  regarded  it  as  one  of  its  causes. 


47*  PATHOLOGY   OF   PREGNANCY. 

Tome  authors  attribute  it  to  diminished  secretion  of  bile.  When  carried 
too  far  it  often  produces  anorexia,  and  disordered  digestion,  and  becomes  a 

cause  of  agitation  and  loss  of  sleep.  Whatever  be  its  cause,  the  straining? 
necessary  to  expel  the  hardened  faeces  that  have  accumulated  in  the  intes- 
tine, may  give  rise  to  hemorrhage  and  abortion. 

The  best  measures  for  preventing  and  remedying  this  state  are  nearly 
identical  with  those  used  at  other  periods  of  life. 

The  same  remarks  apply  to  the  diarrhoea  with  which  women  are  often 
tormented. 

[Constipation,  as  just  said,  is  very  common  during  pregnancy.  Diarrhoea  some- 
times occurs,  and  that  more  frequently  than  seems  to  be  generally  suspected. 

The  diarrhoea  of  pregnancy  varies  in  character,  and  is  due  to  different  causes. 
Sometimes  it  alternates  with  the  constipation  which  gives  rise  to  it,  and  which  is 
relieved  thereby.  At  other  times  it  coincides  so  nearly  with  conception  as  to  be  its 
Bret  symptom  ;  again,  it  may  appear  only  during  the  last  days  of  gestation,  and 
indicate  the  imminence  of  labor.  In  none  of  these  forms  does  it  present  any  gravity, 
and  is  amenable  to  the  treatment  usually  employed  in  such  cases. 

Exceptionally,  however,  severe  diarrhoea  may  supervene  during  pregnancy,  with- 
out any  assignable  cause.  The  passages  are  profuse  and  frequent,  and  accompanied 
with  tenesmus;  emaciation  takes  place  with  exhaustion  of  strength,  the  mouth 
becomes  dry,  and  fever  sets  in. 

Some  of  these  cases  resist  all  kinds  of  treatment,  and  may  lead  to  abortion  or 
premature  labor.  This  form,  to  which  the  term  intractable  might  well  be  applied, 
may  prove  fatal  to  the  mother  either  before  or  after  delivery.  One  case  of  the  kind 
me  under  our  own  observation.] 

ARTICLE    II. 

LESIONS    OF    RESPIRATION. 

Cough  and  dyspnoea  are  about  the  only  affections  claiming  our  examina- 
tion under  this  title. 

The  dyspncea  that  supervenes  towards  the  end  of  pregnancy  is  evidently 
produced  by  the  crowding  of  the  lungs  from  the  excessive  uterine  develop- 
ment, and  the  delivery  alone  can  cure  it;  but  sometimes  it  is  sooner  mani- 
fested  in  consequence  of  a  pulmonary  congestion,  which  must  be  remedied 
by  general  blood-letting,  a  light  regimen,  repose  in  a  suitable  position,  and 
loose  clothing. 

The  same  may  be  said  of  such  palpitations  as  are  not  due  to  organic  dis- 
ease which  existed  before  the  pregnancy  ;  but  it  must  not  be  forgotten  that, 
though  bleeding  is  useful  when  the  dyspnoea  or  palpitations  are  very  severe, 
by  diminishing  the  local  congestion  for  the  time,  the  latter  is  much  more 
frequently  due  to  hydraemia  than  to  a  true  plethora,  and  that  the  best 
means  for  preventing  its  return  is  to  follow  the  bleeding  by  tonic  remedies. 
(See  the  following  article.) 

As  to  the  cough,  it  is  only  dangerous  as  regards  the  pregnancy,  by  the 
violent  jars  sometimes  given,  which  may  produce  an  abortion.  Indeed,  all 
observers  who  have  written  on  influenza  have  carefully  noted  the  frequency 
of  this  accident  in  women  who  were  affected  with  it. 

Winn  tin  cough  is  the  effect  of  pregnancy,  it  may  sometimes  be  attributed 


DISEASES     OF     PREGNANCY.  479 

to  local  plethora,  and  then  we  should  bleed.  But  at  other  times  it  has  a 
spasmodic  character  resembling  whooping-cough,  with  the  exception  of  the 
alteration  of  the  voice.  In  such  cases,  I  have  derived  much  advantage 
from  baths,  repeated  for  several  days  in  succession. 

When  it  is  the  symptom  of  a  chronic  malady,  existing  prior  to  gestation, 
the  treatment  will  vary  with  the  disease  that  produced  the  cough.  What- 
ever may  be  its  origin,  the  accoucheur  should  always  resort  to  such  demul- 
cents and  pectorals  as  are  calculated  to  diminish  its  intensity. 


ARTICLE    III. 
lesions  of  the   circulation. 

§  1.  Alterations  of  the  Blood.     Plethora  and  Hydremia. 

The  general  circulation  is  more  active  in  pregnant  women  than  in  others 
(see  page  157),  and  this  increased  activity  manifests  itself  by  a  greater  fre- 
quency of  pulse,  which  is  often  harder  and  fuller  than  in  the  non-gravid 
state.  Though  all  this  may  be  regarded  as  normal,  it  sometimes  becomes 
exaggerated  and  gives  rise  to  a  slightly  morbid  condition.  Thus,  some 
women  experience,  at  the  same  time,  vertigo,  dimness  of  vision,  ringing  of 
the  ears,  sudden  flushings  of  the  face,  spontaneous  heats  over  the  body,  but 
more  especially  of  the  head.  If  bleeding  be  practised  under  these  circum- 
stances, the  blood  will  sometimes  afford  a  large  and  consistent  clot  with  but 
little  serum ;  though  much  more  frequently  there  is  much  serum,  and  a 
small  clot,  covered  with  a  distinct  whitish  coat,  resembling  that  observed 
in  inflammatory  diseases.     (See  page  160.) 

The  differences  in  the  appearance  of  the  blood  drawn  by  venesection  ought 
to  have  excited  the  suspicion  that,  notwithstanding  their  identity,  these 
functional  disturbances  might  be  produced  by  different  causes  ;  and  although 
some  scattering  therapeutic  measures  induce  the  supposition  that  the  idea 
had  suggested  itself  to  some  good  minds,  it  is  also  evident  that  it  was  almost 
immediately  stifled ;  for  the  majority  of  authors,  even  the  most  recent,  do 
not  hesitate  to  refer  them  to  plethora,  and  making  the  treatment  correspond 
with  the  etiology,  recommend  blood-letting  as  the  best  means  of  overcom- 
ing it. 

The  little  advantage  which  I  had  derived  from  this  practice  had,  lor 
several  years,  excited  doubts  in  my  mind  as  to  the  value  of  the  theory; 
which  doubts  were  especially  increased  by  reading  the  admirable  investi- 
gations by  M.  Andral  on  the  blood.  Therefore,  in  treating,  in  1844,  in  the 
second  edition  of  this  work,  of  the  plethora  of  pregnant  females,  I  wrote  as 
follows:  "After  having  read  the  curious  statements  just  given  (analysis  <>/ 
the  blood  by  M.  Andral),  the  reader  will  perhaps  find  them  to  disagree  with 
the  title  of  this  paragraph,  and  possibly  also  with  the  therapeutic  measures 
hereafter  recommended;  for  how,  indeed,  can  we  reconcile  this  denomination 
of  plethora,  applied  to  the  totality  of  the  phenomena  observed  in  most  gravid 
females,  with  the  evidences  of  anaemia  furnished  by  the  analysis  of  the 
blood  ?  Is  it  not  probable  that  the  profession  has  heretofore  been  in  error,  in 
attributing  to  this  cause  what  in  fact  is  only  due  to  an  impoverishment  of 


480  PATHOLOGY   OF    PREGNANCY. 

the  blood?  Because,  if  to  these  results  we  add  the  beating  of  the  carotids, 
the  caprices  of  the  stomach,  the  digestive  disorders,  and  the  varied  nervous 
phenomena  that  occur  during  pregnancy,  and  which  closely  resemble  those 
so  often  observed  in  chlorotic  patients,  are  we  not  irresistibly  brought  to  the 
conclusion,  that  the  chlorosis  which  produces  them  in  the  one  case  also  does 
in  the  other?  and,  consequently,  that  the  bleeding  generally  recommended 
is  more  likely  to  augment  than  to  diminish  such  disorders?  A  sufficient 
number  of  facts  are  still  wanting  to  decide  the  question  satisfactorily;  but, 
while  presenting  in  this  work  the  views  most  generally  received,  we  cannot 
conceal  the  effects  produced  on  our  mind  by  the  experiments  of  Andral  and 
Gavarret." 

From  that  time  we  have  endeavored  to  test  by  facts  the  inferences  which 
we  had  drawn  from  the  documents  furnished  by  the  experiments  of  these 
two  learned  professors;  and  we  have  to  say,  that  the  theory  is  confirmed  by 
practice.  Therefore  we  now  assert  boldly,  what  we  before  expressed  timidly 
in  a  simple  note:  That  hydroemia  is  the  most  frequent  cause  of  those  func- 
tional disorders  of  pregnant  women  which  have  hitherto  been  attributed  to 
plethora. 

However  strange  this  proposition  may  at  first  appear,  it  seems  to  us  to 
be  proved  by  the  results  of  the  chemical  analysis  of  the  blood,  by  the 
symptoms  presented  by  the  patients,  and  by  the  happy  effects  of  a  tonic 
treatment. 

It  is  now  well  proved  that  the  essential  character  of  plethora  is  based 
upon  a  great  increase  in  the  proportion  of  the  blood  corpuscles,  as  their 
diminution  is  the  distinctive  fact  in  anaemia.  And  it  is  well  known  that 
diminution  of  the  corpuscles  and  increased  proportion  of  water  are  the 
essential  characteristics  of  anaemia  and  chlorosis.  Now  we  have  shown 
(pp.  157  and  159)  whilst  describing  the  changes  in  the  blood  during  preg- 
nancy, that  the  amount  of  corpuscles  diminishes,  whilst  that  of  water 
increases.  In  this  respect,  therefore,  pregnant  women  may  be  strictly  com- 
pared with  those  affected  with  chlorosis.  The  increase  of  fibrin  and  dimi- 
nution of  albumen  also  observed  during  gestation  (see  pages  157  to  159  ,  are 
of  more  difficult  explanation. 

The  deficient  nutrition  of  the  mother,  who  is  obliged,  whatever  may 
happen,  to  supply  the  fetus  with  the  food  required  for  its  development, 
may  also  explain  the  excess  of  fibrin,  and  in  addition,  the  decrease  of  the 
corpuscles;  for  the  experiments  of  M.  Andral  have  shown  that  the  blood 
of  dogs,  subjected  to  certain  degrees  of  abstinence,  presented  the  characters 
of  chloro-anaemia,  and  coincided  with  a  marked  increase  of  the  fibrin. 
Again,  if  we  admit,  with  some  modern  chemists,  that  the  fibrin  is  formed 
at  the  expense  of  the  albumen  of  the  blood,  may  we  not  find  in  the  con- 
siderable diminution  of  the  latter  the  cause  of  the  increase  of  the  former? 

Finally,  we  would  add  that  MM.  Becquerel  and  Rodier,  the  only  ob- 
servers whose  analyses  give  the  proportion  of  iron  in  the  blood  of  pregnant 
women,  have  shown  that  it  is  below  the  physiological  average.  Thus,  in 
1000  grammes  of  the  calcined  blood  of  a  healthy  and  non-pregnant  woman, 
the  average  proportion  of  iron  is  0*54]  ;  in  that  of  the  pregnant  female  it  is 
0'449;  and  in  well-marked  chlorosis  it  is  0'oGG.     The  proportion  of  iron 


DISEASES     OF     PREGNANCY. 


481 


t&llows,  therefore,  that  of  the  corpuscles,  and  the  expression  of  its  amount 
during' pregnancy  will  serve  to  indicate  the  transition  from  the  healthy 
condition  to  confirmed  chlorosis. 

From  all  that  has  been  said,  we  think  it  may  be  concluded  that  the  prin- 
cipal elements  of  the  blood  undergo  alterations  during  pregnancy  analogous 
to  those  of  chlorosis.  These  changes  are  doubtless  in  many  cases  purely 
physiological,  as  we  have  already  stated  (see  page  159),  but  may  so  increase 
as  to  become  pathological   by  the  establishment  of  hydrsemia  and  chloro- 

ansemia. 

The  view  which  we  take  will  become  still  clearer  when  we  shall  have 
proved  the  following  proposition. 

The  Functional  Disorders  of  Pregnancy  hitherto  attributed  to  Plethora  are 
those  of  Chlorosis.  Most  of  the  authors  who  have  written  upon  the  func- 
tional disorders  of  pregnancy  have  attributed  them  to  plethora,  on  account 
of  the  peculiar  physiognomy  which  they  present.  Thus,  because  in  many 
pregnant  females  they  observed  fulness  and  hardness  of  the  pulse,  a  feeling 
of  heaviness  in  the  head  with  somnolence,  vertigo,  ringing  in  the  ears, 
flashes  of  heat,  sudden  flushings  of  the  face,  &c,  they  regarded  them  un- 
hesitatingly as  the  expression  of  encephalic  congestions,  themselves  the  con- 
sequence of  general  plethora. 

Now  it  is  really  only  necessary  to  read  the  list  of  symptoms  belonging  to 
chlorosis,  in  order  to  be  convinced  that  they  are  identical  for  the  two 
affections. 

This  is  easily  explained,  says  M.  Andral,  by  observing  that  if  the  mere 
passage  of  too  great  an  amount  of  corpuscles  through  the  vessels  of  the  brain 
appears  to  account  sufficiently  for  the  cerebral  disorders  witnessed  in  ple- 
thora, it  follows  that  too  small  an  amount  of  corpuscles  traversing  the  same 
vessels  will  produce  similar  disorders ;  so  that  too  great  or  too  small  ar 
amount  of  corpuscles  deranges  certain  actions  of  the  brain  in  the  same 
manner.  Therefore,  the  true  cause  of  the  symptoms  is  not  to  be  judged  of 
by  their  external  characters,  but  only  by  the  changes  in  the  bloody  Now, 
the  analysis  of  the  blood  of  a  large  number  of  females,  who  complained  of 
these  supposed  plethoric  phenomena,  has  shown  a  marked  diminution  of 
corpuscles  and  an  increase  of  serum. 

Besides,  if  we  remember  what  has  already  been  said  concerning  the 
pathology' of  pregnancy,  it  will  be  found  that  there  is  hardly  one  of  the 
functional  disorders  yet  studied,  which  is  not  also  observed  in  chlorotio 
women.  What  is  more  common  than  to  find  in  chloro-ancemic  patients  the 
want  of  appetite,  disgust  for  food,  whimsical  and  depraved  tastes,  cramps 
and  pains  in  the  stomach,  nausea  and  vomiting,  —  in  short,  all  those  symp- 
toms of  gastralgia  which  render  many  pregnancies  so  suffering?  Are  not 
also  the  headaches,  toothaches,  faintings,  and  the  facial,  frontal,  orbital,  or 
temporal  neuralgias,  common,  so  to  speak,  to  the  two  conditions?  As  re- 
gards the  circulation,  do  we  not  observe  the  same  modifications  in  the 
strength  of  the  impulse,  the  rhythm,  and  the  clearness  of  the  pulsations  of 
the  heart,  and  is  not  a  bellows  murmur  also  heard  in  the  principal  vascular 

trunks? 

Some  of  these  various  disorders,  such  as  the  nervous  phenomena,  arc  moif 
31 


482  PATHOLOGY   OF   PREGNANCY. 

particularly  observed  in  the  first  half  of  pregnancy;  others,  such  as  the 
pretended  symptoms  of  plethora,  trouble  more  especially  those  females  who 
have  reached  a  more  advanced  period.  It  must,  however,  be  confessed, 
that  sometimes  all  of  them  appear  at  the  beginning,  and  sometimes  at  the 
end  of  gestation,  which  fact  some  persons  have  thought  to  militate  against 
my  theory.  Why,  said  M.  Jacquemier,  should  the  same  symptoms,  which 
are  regarded  as  disorders  due  to  sympathy  with  the  uterus,  if  they  appear 
during  the  first  half  of  pregnancy,  be  considered  as  caused  by  chlorosis,  it' 
they  appear  during  the  second  half?  Is  there  not  something  arbitrary  and 
artificial  in  this, — something  which  seems  to  have  been  devised  expressly 
for  the  support  of  a  theory? 

In  the  first  place,  I  would  observe  that  I  have  only  spoken  of  the  un 
comfortable  sensations  which  women  experience  in  the  latter  months;  bui 
in  supposing  the  similarity  of  the  symptoms,  there  is  nothing  irrational  in 
attributing  to  them  a  different  origin.  I  may  be  allowed  to  recall  what 
takes  place  in  t  lie  case  of  a  young  girl  becoming  chlorotic :  it  will  be  seeD 
that  the  succession  of  phenomena  is  absolutely  the  same  as  what  I  hav« 
supposed  for  the  chlorosis  of  pregnant  women.  A  healthy  young  girl 
reaches  the  age  of  puberty,  when,  under  the  influence  of  causes  which  we 
often  cannot  appreciate,  the  menstruation  fails  to  become  established,  or 
takes  place  only  in  an  imperfect  or  irregular  manner.  The  uterus,  being 
disturbed  in  the  exercise  of  its  monthly  functions,  soon  reacts  upon  all  the 
other  organs.  The  appetite  diminishes,  the  stomach  becomes  capricious, 
the  tastes  whimsical,  the  digestion  painful ;  and  from  the  persistence  of  this 
difficult  digestion  results  incomplete  assimilation,  and  soon  deficient  nutri- 
tion. After  the  lapse  of  a  few  weeks  or  months,  the  defective  nutrition 
produces  an  alteration  in  the  composition  of  the  blood,  which,  when  carried 
to  a  certain  degree,  produces  all  the  symptoms  of  chlorosis, — symptoms 
bearing  a  strong  resemblance  to  those  which  preceded  and  caused  the 
general  disease  of  which  they  are  the  expression. 

No  one,  certainly,  will  deny  the  truth  of  the  picture  just  drawn.  Now,  is 
not  the  same  succession  of  phenomena  witnessed  in  pregnancy?  In  both 
is  it  not  the  irritation  of  the  uterus  produced  by  the  new  functions, 
which  lirst  reacts  upon  the  other  functions  of  the  economy,  disturbing  their 
regular  fulfilment,  which  afterward  interferes  with  the  assimilation  of  nutri- 
tive matters,  and  which  finally  produces  chlorosis?  Is  not  the  latter  con- 
dition indicated  in  the  pregnant  woman,  as  in  the  young  girl,  by  the  same 
symptoms?  Where  then  is  the  difference?  And  if  it  be  allowed  that  the 
primary  functional  disorders  of  the  young  girl  are  purely  sympathetic, 
whilst  those  which  occur  later  are  attributable  to  chlorosis,  why  should  we 
refuse  to  acknowledge  the  same  as  occurring  during  pregnancy? 

After  thus  recalling  the  fact,  that  all  the  functional  disorders  of  chlorosis 
are  sometimes  observed  during  pregnancy,  it  truly  becomes  a  matter  of 
astonishment  that  the  resemblance  between  the  two  should  not  have  been 
noted  earlier,  and  that  it  should  have  been  left  for  recent  analyses  to  ( xcite 
the  suspicion  that  the  same  symptoms  might  be  due  to  the  same  cause. 

The  pathological  anatomy  and  symptomatology  being  then  in  accordance 
with  each  other,  it  remains  to  be  .-ecu  whether  the  treatment  will  afford 
another  evidence  of  the  nature  of  the  disorder. 


DISEASES    OF    PREGNANCY.  ±83 

Plethora  was  formerly  considered  so  common,  and  so  exclusively  the 
cause  of  the  diseases  of  pregnancy,  that  blood-letting  had  become  a  general 
practice.  So  strongly  impressed  were  many  women  with  the  idea  of  the 
necessity  of  bleeding,  that  they  thought  themselves  under  an  obligation  to 
have  recourse  to  it  by  the  time  they  had  reached  the  fifth  month  of  gestation, 
and  even  demanded  it  before  consulting  their  physician.  Most  practitioners 
declined  performing  these  so-called  preventive  bleedings,  though  all  re- 
garded venesection  as  the  best  means  of  overcoming  plethora,  that  is  to  say, 
the  assemblage  of  phenomena  attributed  thereto.  If  the  latter  proposition 
were  true,  it  would  constitute  an  unanswerable  objection  to  the  theory  we 
are  endeavoring  to  establish.     Fortunately,  however,  such  is  not  the  case. 

I  certainly  do  not  wish  to  deny  the  amelioration  produced  by  bleeding 
in  certain  cases  ;  but  it  proves  nothing  against  the  poverty  of  the  blood, 
and  the  chloro-anremia.  The  lessened  proportion  of  the  corpuscles  does 
not  necessarily  involve  a  diminution  of  the  entire  mass  of  the  blood,  as  the 
word  ancemia  applied  to  this  alteration  would  seem  to  indicate.  Generally, 
on  the  contrary,  the  amount  of  this  fluid  remains  the  same,  and  sometimes 
even  is  considerably  increased';  thus  corresponding  with  what  M.  Beau 
states  to  be  habitually  the  case  in  chlorosis.  A  true  plethora,  which  might 
be  styled  serous,  then  exists,  in  which  case,  especially  to  the  usual  signs  of 
anaemia,  are  superadded  headache,  vertigo,  ringing  in  the  ears,  etc. ;  and 
under  these  circumstances,  bleeding  may  afford  relief  by  diminishing  the 
amount  of  blood.  The  same  result  is  obtained  in  ordinary  chlorosis,  when 
bleeding  is  practised  for  the  removal  of  local  congestions.  But,  in  preg- 
nancy as  in  chlorosis,  this  alleviation  is  but  temporary,  and  if  the  propor- 
tion of  corpuscles  be  not  brought  up  to  the  healthy  standard  by  proper 
hygienic  and  therapeutic  measures,  the  same  symptoms  will  soon  reappear, 
and  with  greater  intensity.  The  abstraction  of  blood  is,  therefore,  in  any 
case,  but  a  palliatory  measure,  only  to  be  employed  in  extreme  cases,  when  the 
general  symptoms  are  very  severe,  but  which  might  have  been  avoided 
by  administering  tonics  and  ferruginous  preparations  at  an  earlier  period. 

An  animal  diet,  and  preparations  of  iron,  have,  for  six  years  back, 
always  appeared  to  me  to  be  quite  as  useful  against  the  functional  disorders 
of  pregnancy  as  against  those  of  chlorosis.  Unless  they  be  very  serious, 
I  no  longer  bleed  for  palpitations,  pains  in  the  head,  or  suffocations,  nor 
have  I  known  them,  in  a  single  instance,  to  resist  the  use  of  the  prepara- 
tions of  iron  longer  than  a  couple  of  weeks.  Even  when  the  gravity  of  the 
accidents  has  obliged  me  to  bleed  to  the  extent  of  six  or  eight  ounces  at 
the  utmost,  I  begin  immediately  with  the  use  of  iron,  and  it  is  very  rarely 
that  I  am  obliged  as  formerly  to  recur  to  venesection.  Hemorrhage  from 
the  bowels  might,  in  some  cases,  remove  the  necessity  for  phlebotomy,  and 
M.  Blot  was  certainly  right  in  advising  gentle  purgatives  under  these 
circumstances. 

There  is  still  another  condition,  in  which  I  have  associated  iron  and 
bleeding  with  advantage;  with  what  propriety  we  shall  next  see. 

The  excess  of  impoverished  blood  in  pregnancy  may,  as  in  chlorosis,  give 
rise  to  local  congestion,  which  congestion,  when  carried  beyond  certain 
limits,  explains  the  occurrence  of  epistaxis,  and  the  l^ss  frequent  hoemop- 


18-1  PATHOLOGY    OF    PREGNANCY. 

tysia  and  hrematemesis,  all  which  seem  to  be  the  result  of  an  effort  on  the 

part  of  nature  to  diminish  the  vascular  fulness.  These  accidents  are 
unusual  during  pregnancy,  or,  at  least,  rarely  occur  to  an  alarming  extent. 
The  reason  seems  to  be,  that  from  the  moment  of  conception  until  delivery. 
all  the  vital  powers  appear  to  be  concentrated  upon  a  single  organ,  which 
forms  a  centre  of  fluxion,  towards  which  all  the  troubles  of  the  organism 
converge;  this  organ  is  the  uterus.  The  congestion,  which  in  the  chlorotic 
patient  occurs  in  the  head  or  the  chest,  here  takes  place  in  the  womb ;  and 
the  extraordinary  development  of  the  vessels  of  the  uterus,  and  their  more 
or  less  intimate  connection  with  those  of  the  fetus,  sufficiently  explain  the 
danger  of  an  over-determination  of  fluid.  At  a  very  early  period,  the 
congestion  may  occasion  the  rupture  of  one  of  the  numerous  capillary 
vessels  distributed  upon  the  internal  surface  of  the  mucous  membrane 
[parietal  or  epichorial  decidua)  ;  rather  later,  the  congestion  may  be  great 
enough  to  rupture  one  of  the  utero-placental  vessels,  and  in  both  cases  give 
rise  to  an  effusion,  which,  by  destroying  wholly  or  in  part  the  utero-placental 
relations,  proves  fatal  to  the  child. 

These  uterine  congestions,  which  are  properly  considered,  in  some  cases, 
as  the  consequence  of  general  plethora,  I  have  witnessed  much  oftener  in 
feeble  and  anyemic  women.  They  almost  always  appear  at  the  menstrual 
periods,  as  though  the  monthly  periodicity  excited  at  those  times  a,  more 
active  vitality  in  the  uterus.  The  woman  complains  of  tension,  of  swelling 
of  the  abdomen,  of  a  feeling  of  weight  in  the  pelvis,  the  groins,  and  upper 
part  of  the  thighs ;  she  also  soon  suffers  pain  in  the  region  of  the  kidneys 
and  in  the  loins.  If  the  proper  measures  are  not  employed,  the  vascular 
congestion,  and  the  pressure  upon  the  uterine  walls  resulting  from  it,  irri- 
tate the  organ  ;  slight  contractions  occur,  sometimes  even  a  little  blood 
flows  from  the  vulva,  and  announces  a  threatened  abortion.  These  symp- 
toms are  almost  always  accompanied  with  marked  vesical  tenesmus.  Can 
the  latter  be  due  to  pressure  on  the  neck  of  the  bladder,  produced  by  an 
increase  in  the  size  and  weight  of  the  uterus  caused  by  the  congestion  ? 

It  is  evident  that  when  these  symptoms  of  uterine  congestion  appear, 
prudence  dictates  a  recourse  to  all  the  means  likely  to  effect  a  revulsion. 
Thus,  sinapisms  to  the  upper  and  posterior  part  of  the  back,  seven  or  eight 
dry  cups  to  the  upper  part  of  the  chest,  and  finally,  if  these  measures  are 
insufficient,  bleeding,  to  the  extent  of  six  or  eight  ounces,  as  a  powerful 
revulsive,  is  very  useful.  But,  even  here,  the  bleeding  may  have  only  a 
momentary  effect  by  destroying  the  local  plethora,  and  by  no  means  enables 
us  to  dispense  with  medicines  capable  of  modifying  the  state  of  the  blood. 
We  shall  return  to  this  subject  under  the  head  of  Preventive  Treatment  of 
Abortion.  It  is  proper,  however,  that  I  should  say  in  this  place,  that  many 
of  my  patients  who  had  suffered  frequent  miscarriages,  have  been  enabled 
to  attain  their  full  period  by  the  use  of  iron  administered  from  the  begin- 
ning of  pregnancy. 

We  see,  therefore,  and  I  call  the  attention  of  practitioners  to  this  point, 
that  if  the  medicament  which  cures  a  disease  sometimes  also  proves  it? 
nature,  then  the  disorders  which  we  have  described  are  oftenest  due  to 
chloro-ansemia,  and  not  to  plethora.     The  latter  proposition,  confirmed  as 


DISEASES   OF   PREGXAXCY.  485 

it  is  by  pathological  anatomy  and  symptomatology,  I  hold  to  be  incon- 
testable. 

I  say  oftenest,  for  I  would  not  have  my  assertion  regarded  as  absolute. 
Though  true  plethora,  that  which  is  distinguished  from  serous  plethora  by 
an  increase  in  the  amount  of  the  corpuscles,  be  rare,  it  nevertheless  is  some- 
times met  with,  especially  at  a  very  early  stage  of  gestation.  Females  of  a 
really  plethoric  constitution,  whose  menstrual  discharge  is  habitually  abun- 
dant and  high-colored,  may  retain  this  constitutional  peculiarity  during 
pregnancy,  and  sometimes  even  have  it  increased.  The  sixty  odd  analyses 
which  w-e  have  quoted,  show  that,  in  several  instances,  the  proportion  of 
corpuscles  underwent  no  diminution  in  the  earlier  months,  and  that  in  the 
case  of  one  woman  who  had  reached  the  end  of  the  second  month,  M. 
Andral  found  them  increased  to  one  hundred  and  forty-five.  It  is  even 
probable  that,  when  analyses  shall  be  more  numerous,  the  same  peculiarity 
will  be  remarked  in  some  cases  of  advanced  pregnancy.  For  my  own  part, 
I  have  certainly  met  with  females  whose  antecedents,  symptomatic  expres- 
sion, and  the  physical  properties  of  whose  blood  afforded  every  indication 
of  plethora. 

The  fact  of  our  having  observed  but  few  instances  of  the  latter  class,  is 
explained  by  our  practising  in  the  metropolis,  where  all  debilitating  influ- 
ences are  collected.  The  hygienic  conditions  in  which  women  live  in  the 
country,  dispose  them  less  to  chlorosis,  and  it  is  exceedingly  probable  that 
their  blood  is  not  so  much  altered  during  pregnancy  as  in  the  cases  we  have 
noticed.  To  this,  I  think,  is  certainly  due  their  exemption  from  the  func- 
tional disorders,  nervous  or  otherwise,  which  so  commonly  affect  the  females 
of  large  cities.     This  is  an  additional  argument  in  favor  of  my  theory. 

Though  such  women  are  exposed  to  the  general  consequences  of  plethora, 
they  present  more  frequently  the  signs  of  local  or  uterine  plethora,  espe- 
cially during  the  first  half  of  pregnancy,  at  the  periodic  returns  of  the 
menstrual  periods.  The  local  phenomena,  as  tension,  swelling  of  the  abdo- 
men, feeling  of  weight  in  the  pelvis,  are  very  strongly  marked  in  their 
cases.  The  circulation  of  the  foetus  also,  sometimes,  appears  to  share  in 
the  troubles  of  the  maternal  circulation,  for  these  signs  of  congestion  are 
frequently  observed  to  be  followed  by  the  weakening,  diminished  frequency, 
and  even  complete  cessation  of  its  active  motions;  and  if  the  motions  have 
not  yet  been  perceived,  the  plethoric  condition  may  greatly  retard  their 
appearance.  However  difficult  the  explanation  of  these  peculiarities  may 
appear,  they  are  too  common  to  be  doubted.  The  best  proof  that  can  be 
given  of  the  effect  of  this  local  congestion  upon  the  motions  of  the  child, 
is  their  prompt  reappearance  after  a  venesection  made  at  the  proper  time; 
and  it  very  frequently  happens  that  a  woman  who  is  five  months,  or  five 
months  and  a  half,  gone,  without  having  felt  them,  perceives  them  suddenly 
after  bleeding. 

It  is  unnecessary  to  state  that  here  blood-letting  constitutes  the  proper 
treatment,  and  that  the  quantity  abstracted  maybe  regulated  by  the  cir- 
cumstances of  the  individual  cases.  It  is,  however,  better  to  practise 
several  small  bleedings  at  short  intervals,  than  to  depend  upon  a  single 
uopious  one.     The  pioduction  of  syncope  should  be  studiously  avoided. 


186  PATHOLOGY    OF    PREGNANCY. 

We  shall  have  occasion,  when  treating  of  ahortion,  to  finish  (he  stud) 
of  the  therapeutical  indications.     (See  Abortion.) 

To  recapitulate,  the  functional  disorders  of  pregnancy,  as  cephalalgia, 
giddiness,  vertigo,  ringing  in  tin;  ears,  dyspnoea,  palpitations,  &c,  are  rarely 
due  to  true  plethora,  hut  most  generally  to  chloro-anaemia.  We  might 
iudeed  distinguish  for  pregnant  women  a  very  rare  sanguineous  plethora, 
and  a  very  common  serous  plethora. 

Independently  of  this  marked  diminution  of  glohules  and  albumen,  the 
hlood  is  sometimes  considerably  altered  by  admixture  with  the  elements  of 
the  urine.  This  alteration,  which  has  been  described  of  late  by  the  Ger- 
mans under  the  title  of  uroemia,  and  of  which  we  shall  soon  have  occasion 
to  speak,  is  a  capital  fact  in  the  etiology  of  several  diseases  which  are  liable 
to  appear  in  the  puerperal  condition.  We  merely  state  the  fact  for  the 
present,  leaving  further  notice  of  it  uutil  we  come  to  treat  of  the  lesions  of 
the  urinary  secretion. 

§  2.  Hemorrhage. 

[Hemorrhage  from  the  genital  organs  is,  unfortunately,  but  too  common  during 
pregnancy,  and  is  an  accident  much  to  be  apprehended.  The  hemorrhage  may 
assume  very  different  features  according  to  the  cause  which  produces  it  and  the 
time  of  its  appearance.  On  this  account  it  would  be  so  difficult  to  treat  of  it  in  a 
single  chapter,  that  its  history  must  necessarily  he  divided  into  several  articles, 
which  we  think  it  best  thus  to  indicate  at  the  outset.  Sometimes  the  effusion  of 
blood  is  confined  to  the  placenta,  and  has  already  been  described  as  placental  apo- 
plexy with  the  other  diseases  of  the  placenta  (see  Diseases  of  the  Ovum).  Uterine 
hemorrhage  occurring  during  the  first  six  mouths  of  gestation  should,  if  it  be  some- 
what profuse,  excite  fears  of  abortion,  which  it  often  gives  rise  to  or  accompanies. 
Under  these  circumstances  it  is  impossible  to  separate  the  study  of  the  hemorrhage 
from  that  of  the  abortion.     (See  Abortion). 

Hemorrhage  occurring  during  the  three  last  months  of  gestation  presents,  on  the 
other  hand,  the  same  symptoms,  and  requires  the  same  treatment  as  though  it 
occurred  during  labor.  One  description,  therefore,  suffices  for  both,  and  will  be 
given  in  connection  with  the  history  of  other  accidents  which  are  liable  to  occur 
during  labor.     (See  Dystocia,  article  Hemorrhage.) 

Again,  rupture  of  varicose  veins  of  the  vulva  and  vagina  gives  rise  to  effusion 
of  blood  in  these  organs.  Such  an  effusion  is  known  as  a  thrombus.  As  it  rarely 
occurs  except  during  labor,  we  refer  the  account  of  it  also  to  the  article  on  Dystocia. 
(See  Dystocia,  article  Thromuus.) 

We  shall  merely  refer  in  this  place  to  a  rather  rare  and  curious  form  of  uterine 
hemorrhage.  Some  women  have  a  discharge  of  biood  from  the  vulva  a  few  days 
after  conception.  It  is  small  in  amount  and  is  sometimes  intermittent  and  some- 
time continuous;  it  is  rarely  attended  with  clots,  but  resembles  a  moderate  men- 
strual flow.  It  sometimes  lasts  for  three  or  four  months  without  interruption,  yet 
neither  gives  rise  to  serious  symptoms  nor  interferes  with  the  course  of  gestation; 
finally  it  ceases  without  assignable  cause.  In  our  opinion,  the  discharge  has  it? 
source  in  the  neck  of  the  uterus,  which,  in  these  cases,  has  appeared  to  us  both 
large  and  softened.  The  explanation  would  at  least  seem  probable,  when  we 
remember  how  readily  blood  exudes  from  the  os  tinea)  when  a  pregnant  woman  is 
examined  by  means  of  a  speculum.  An  ulceration  of  the  cervix  vfould  facilitate 
the  discharge  of  blood.  It  requires  no  treatment,  the  greatest  danger  being  that  it 
mighl  Lead  t<>  the  belief  of  the  non-existence  of  pregnancy.! 


diseases  of  pregnancy.  487 

§  3.  Vaetctbs.     Hemorrhoids. 

A  varicose  condition  of  the  veins  in  the  lower  extremities,  the  vagina, 
And  inferior  parts  of  the  rectum,  is  quite  a  common  occurrence  towards  the 
latter  part  of  gestation,  though,  as  regards  treatment,  the  varicose  veins  in 
the  limhs  only  require  the  usual  precautions  to  prevent  their  rupture.  For 
this,  methodical  compression  is  the  best  remedy,  and  every  attempt  at  a 
radical  cure  should  be  discountenanced. 

[Varicose  veins  of  the  limbs  sometimes  burst  during  pregnancy,  and  the  result- 
ing hemorrhage  is  almost  always  serious  in  consequence  of  the  pressure  of  the 
uterus  on  the  iliac  veins.  Though  some  cases  are  said  to  have  proved  fatal,  any 
hemorrhage  of  this  kind  is  generally  easily  arrested  by  well-regulated  pressure 
applied  to  the  seat  of  the  injury. 

The  veins  of  the  vulva,  always  dilated  during  pregnancy,  sometimes  become 
varicose,  giving  the  sensation  of  well-defined  cords.  No  annoyance  usually  results, 
though  some  women  complain  of  a  very  uncomfortable  feeling  of  weight  whilst 
standing.     Moderate  pressure  by  means  of  a  T  bandage  almost  always  affords  relief. 

Rupture  of  one  of  these  varicose  veins  may  give  rise  to  severe  hemorrhage  or 
even  death,  as  in  the  following  case  which  came  under  our  notice  at  the  hospital 
of  the  Clinique.  A  pregnant  woman,  in  other  respects  in  good  health,  was  affected 
with  varicose  veins  of  the  vulva.  One  evening,  whilst  about  retiring,  she  attempted, 
whilst  sporting  with  some  of  the  other  women  in  the  dormitory,  to  leap  from  her 
bed.  Falling  backward,  she  found  herself  seated  upon  a  chair,  the  edge  of  which 
had  struck  against  the  vulva.  A  hemorrhage  so  severe  as  to  prove  fatal  in  a  short 
time,  was  the  immediate  result.  At  the  autopsy,  the  only  lesion  that  I  could  dis- 
cover was  a  contused  wound  about  half  an  inch  in  length  upon  the  external  surface 
of  the  left  internal  labium.  Water  injected  into  the  primitive  iliac  vein  escaped 
rapidly  from  the  little  wound  just  mentioned.  Had  the  cause  of  the  hemorrhage 
been  discovered  as  soon  as  the  accident  occurred,  the  effusion  could  have  been  cer- 
tainly stopped  by  pressure  directly  applied. 

As  the  rupture  of  the  veins  of  the  vagina  and  vulva  occurs  most  frequently  dur- 
ing labor,  we  refer  for  further  particulars  to  the  subject  of  Thrombus.  (See  Dys- 
tocia.^ 

Hemorrhoids,  like  varices,  are  an  ordinary  consequence  of  the  uterine 
pressure  on  the  hypogastric  vessels ;  but  they  may  likewise  be  frequently 
produced  by  constipation,  and  the  attendant  accumulation  of  hard  matters 
in  the  rectum.  The  bleeding  piles  are  generally  less  disastrous  ;  but  the 
others  are  more  grave  and  very  painful.  In  fact,  it  often  happens  that 
women  affected  with  them  can  neither  stand  nor  walk,  and  they  are  even 
troubled  when  seated. 

The  first  indication  is  tc  combat  the  costivencss,  and  then  to  assuage  the 
pain  by  tepid  bathing,  cataplasms,  and  emollient  and  narcotic  lotions,  or 
the  poplar  ointment  may  be  applied  to  the  tumors;  and  where  they  are  in- 
ternal, a  suppository  of  cocoa-butter  might  be  introduced  into  the  rectum. 
Liniments  containing  opium  and  belladonna  will  frequently  relieve  the 
patients;  but  this  is  all  that  we  could  prudently  do  under  the  circum- 
stances. 

When  the  inflammation  and  turgescence  are  very  great,  bleeding  in  the 
arm  is  advisable,  as  this  is  much  preferable  to  the  application  of  lc<  ches  in 
thi  immediate  neighborhood  of  the  tumor;  true,  the  latter  calms  the  pain? 


ASS  PATHOLOGY  OF  PREGNANCY. 

temporarily,  but  then,  in  certain  females,  they  might  bring  on  an  abortion, 
I  have  never  known,  says  Desormeaux,  the  application  of  leeches  on  tho 
tumors,  or  the  incision  of  the  latter,  to  procure  any  durable  relief. 

Where  the  irritation  from  the  piles  seems  to  react  on  the  womb,  and 
threatens  a  uterine  hemorrhage,  M.  Gendrin  has  derived  signal  advantage 
from  cold  applications  around  the  pelvis.  In  those  cases,  says  he,  it  ihe 
hemorrhage  is  imminent,  we  augment  the  activity  of  the  topical  remedies 
placed  directly  over  the  parts  affected,  by  using  cold  baths  to  the  breech  at 
the  same  time,  the  temperature  of  the  water  never  having  been  lower  than 
12°  or  15°  (Centigrade,  equivalent  to  54°  or  59°  Fahr.).  I  have  several 
times  employed  cold  injections  successfully.  The  plan  is  to  take  every 
evening  a  large  cold  enema,  which  after  being  discharged  is  followed  by  a 
Pinal  1  one,  which  ought  to  be  retained. 

We  shall  speak  more  fully  of  the  varicose  condition  of  the  vaginal  veins 
under  the  article  Thrombus  of  the  Vulva. 

ARTICLE  IV. 

lesions  of  the  secretions  and  excretions. 
§  1.  Ptyalism. 

Ptyalism,  or  a  hypersecretion  of  saliva,  sometimes  occurs  during  preg- 
nancy. It  generally  lasts  but  a  short  time,  rarely  more  than  two  months. 
One  case,  however,  is  mentioned  by  M.  Brachet,  in  which  the  salivation 
commenced  in  the  second  month,  and  lasted  for  a  month  after  delivery  ; 
and  I  have  quite  recently  observed  a  similar  instance  in  the  case  of  the 
wife  of  one  of  my  professional  brethren.  It  frequently  returns  in  several 
successive  pregnancies.  I  have  seen  it  continue  between  six  and  seven 
weeks  in  the  two  first  pregnancies  of  a  lady  who  has  since  had  another 
child  without  a  recurrence  of  the  affection  ;  and  M.  Danyau,  Jr.,  mentions 
a  patient  who  was  profusely  salivated  for  five  months  in  her  first  pregnancy, 
and  still  longer  and  more  profusely  in  two  succeeding  gestations. 

However  considerable  the  salivation  may  be,  it  is  rather  a  disagreeable 
inconvenience  than  a  serious  complication.  Though  it  has  in  no  case  mate- 
rially affected  the  health,  some  women  have  been  so  annoyed  with  the  con- 
tinual spitting,  and  the  flow  of  saliva  which  sometimes  deluges  the  pillow  at 
night,  as  to  insist  upon  being  relieved  of  it.  Happily,  in  a  large  proportion 
of  cases,  the  ptyalism  ceases  spontaneously,  for  no  great  confidence  can  be 
reposed  in  the  measures  generally  resorted  to  for  its  removal.  Some  ad- 
vantage, however,  may  be  derived  from  the  use  of  aromatic  infusions  and 
Blightly  astringent  gargles.  Like  Desormeaux,  I  have  found  it  useful  to 
recommend  the  patients  constantly  to  keep  a  little  piece  of  sugar-candy  in 
the  mouth.  Others,  again,  advise  lumps  of  gum  arabic,  and  pieces  of  ice. 
It  is  useful  to  be  acquainted  with  these  various  measures,  if  only  to  keep 
up  the  patience  of  the  sufferer,  by  varying  them  from  time  to  time  until 
the  disorder  ceases  of  its  own  accord. 

Some  authors  seem  to  have  dreaded  the  effect  of  the  sudlen  suppression 
of  a  profuse  salivation.    Two  cases  are  mentioned,in  one  of  which  apoplexy 


DISEASES     OF     PREGNANCY.  489 

and  in  the  other  symptoms  of  suffocation,  appeared  to  result  from  it.  I  do 
not  think  that  the  relation  of  cause  and  effect  has  been  satisfactorily  shown 
in  these  cases,  and  am  tempted  to  believe  that  here,  as  in  many  other  in- 
stances, it  has  been  erroneously  concluded,  post  hoc,  ergo  propter  hoc. 

§  2.  Excretion  of  the  Urine. 

The  renal  secretion  is  rarely  increased  during  pregnancy ;  those  writers 
who  have  stated  the  contrary,  having  been  deceived  by  the  frequent  incli- 
nations to  urinate  which  females  experience  at  certain  periods  of*  pregnancy. 
These  repeated  desires  are  due  to  a  true  vesical  tenesmus,  produced  by  the 
compression  exerted  upon  the  body  and  neck  of  the  bladder  by  the  uterine 
tumor.  They  occur  every  hour,  sometimes  oftener,  and  are  relieved  by  the 
discharge  of  a  few  drops  of  urine. 

The  pressure  of  the  uterus  upon  the  neck  of  the  bladder  is  sometimes  so 
great  as  to  obstruct  the  emission  of  urine,  and  render  it  painful  or  even 
impossible.  This  difficulty  in  urinating  may  occur  in  the  commencement 
of  pregnancy,  either  when  the  pelvis  is  too  large,  and  permits  the  uterus  to 
remain  a  long  time  in  the  excavation,  or  on  the  occurrence  of  a  prolapsus 
uteri,  or  those  other  displacements  of  this  organ  known  as  anteversion  and 
retroversion. 

Most  frequently,  however,  it  appears  towards  the  end  of  gestation,  either 
because  the  uterus,  from  being  pushed  down  by  the  presenting  part  of  the 
foetal  head,  early  engages  in  the  excavation,  or  because  the  womb  is  forcibly 
carried  forwards ;  in  the  latter  case  the  body  of  the  bladder  is  pressed  up- 
wards and  in  front  by  the  uterus,  and  its  neck  forced  against  the  superior 
margin  of  the  symphysis  pubis. 

When  the  anteversion  is  well  marked,  the  body  of  the  bladder  forms  an 
angle  of  the  neck  ;  in  some  cases  it  is  even  lower,  whence  the  introduction 
of  a  catheter  is  then  exceedingly  troublesome.  After  all,  the  difficulty  of 
urinating  still  persists  until  term,  whatever  we  may  do ;  for  we  can  only 
alleviate  it  by  tepid  bathing,  the  horizontal  position,  and  more  particularly 
by  the  use  of  a  bandage  to  sustain  the  abdomen. 

Where  the  retention  is  complete,  the  bladder,  by  becoming  distended, 
may  increase  so  much  in  size  as  to  reach  the  umbilicus,  and  its  excessive 
distention  might  produce  an  inflammation  or  even  a  rupture,  especially 
during  the  throes  of  labor;  but  where  the  neck  is  not  altogether  obliterated 
by  the  pressure,  an  incontinence  of  urine  may  ensue,  the  fluid  dribbling 
away  drop  by  drop ;  though,  unfortunately,  that  is  not  always  the  case,  and 
the  catheter  must  then  be  resorted  to. 

I  have  already  said  this  operation  is  attended  by  difficulties  under  such 
circumstances,  and  when  it  is  quite  impossible  to  perform  it,  the  distress 
may  be  relieved,  in  a  measure,  by  pressing  back  the  uterus  from  the  sym- 
physis pubis  with  the  two  fingers  introduced  into  the  vagina,  and  the  woman 
should  be  taught  to  aid  herself  in  this  way. 

In  some  instances,  the  female  suffers  at  the  latter  stages  a  considerable 
smarting  or  pain  in  urinating,  as  sharp  as  if  there  was  a  stone  in  the  blad- 
der;  these  symptoms  arise  from  a  true  catarrh  of  the  body,  or  at  least  of 
the  neck  of  this  organ ;  the  urine,  in  fad,  often  contains  whitish  flakes  of 
purulent  matter.     Such  symptoms  require  the  general  antiphlogistic  treat- 


190  PATHOLOGY   OF    PREGNANCY. 

ment,  local  bathing,  emollients,  and  mucilaginous  drinks.  As  a  general 
rule,  women  only  suffer  from  an  incontinence  of  urine  during  the  last  three 
months,  and  then  the  delivery  is  the  only  remedy;  however,  it  shows  itself 
in  the  early  stages  of  gestation  in  certain  females,  being  evidently  produced 
by  the  pressure  which  the  uterus,  that  is  still  within  the  pelvis,  makes  on 
the  neck  of  the  bladder,  and  it  lasts  until  the  womb  rises  above  the  superior 
strait.  If  the  incontinence  remains  after  the  fifth  month,  the  symptoms  may 
be  relieved  by  injections  of  warm  water,  and  by  the  internal  use  of  tonics. 

Though  the  amount  of  urine  is  not  changed,  its  composition  sometimes 
undergoes  alterations  which  it  is  important  to  be  acquainted  with. 

I  shall  not  return  to  the  consideration  of  the  peculiar  pellicle  called 
kyesteine  by  M.  Nauche,and  whose  diagnostic  value  we  have  already  deter- 
mined ;  but  I  shall  proceed  to  notice  a  very  remarkable  fact,  which  we  shall 
often  have  occasion  to  refer  to ;  I  speak  of  the  presence  of  albumen, 
which  is  found  in  greater  or  less  amount  in  the  urine  of  some  women  at  an 
advanced  stage  of  pregnancy.     (See  Albuminuria.) 

§  3.  Albuminuria.    Uk.t.mia. 

The  credit  of  having  called  the  attention  of  physicians  to  the  presence 
of  albumen  in  the  urine  of  pregnant  women  belongs  to  M.  Raver,  whose 
admirable  and  laborious  investigations  of  the  disease  of  the  kidneys  have 
thrown  so  much  light  upon  the  pathology  of  those  organs.  He  was  the 
first  to  endeavor,  in  his  splendid  work,  to  determine  the  effect  of  this  altera- 
tion of  the  urinary  secretion  upon  the  health  of  the  mother,  and  the  regular 
development  of  the  fcetus.  Afterward,  followed  the  observations  of  Dr. 
Lever  and  of  Dr.  Gahen,  who,  by  the  advice  of  his  master,  M.  Rayer,  pub- 
lished a  good  thesis  upon  the  subject.  Next  came  the  interesting  memoir 
Df  MM.  Devilliers  and  Regnauld,  and  another  thesis  by  M.  Blot.  More 
recently,  two  manuscript  memoirs  by  MM.  Imbert  Goubeyre,  and  Bach, 
and  the  researches  of  French,  Schott,  and  Wieger,  have  shed  some  light 
upon  this  still  obscure  point  of  puerperal  pathology. 

It  is  known  that  albuminuria  is  generally  the  symptom  of  an  organic  dis- 
ease of  the  kidneys,  which  almost  always  proves  fatal;  hence,  it  may  be 
readily  understood,  that  when  this  change  in  the  urine  is  observed  during 
pregnancy,  it  becomes  at  once  desirable  to  ascertain  whether  it  be  neces- 
sarily due  to  the  same  cause,  or  whether  it  be  merely  one  of  the  numerous 
modifications  produced  in  the  economy  by  gestation. 

In  the  first  case,  it  is  a  very  serious  affection,  calculated  to  awaken  all 
the  solicitude  of  the  physician  ;  in  the  second,  it  is  but  a  temporary  func- 
tional disorder,  which  will  most  probably  disappear  with  the  cause  that  pro- 
duced it.  Unfortunately,  in  the  present  state  of  our  knowledge,  it  is  very 
difficult  to  decide  the  question.  For,  on  the  one  hand,  1.  The  normal 
diminution  of  the  albumen  in  the  blood  of  pregnant  women,  which  diminu- 
tion is  much  greater  in  patients  affected  with  albuminuria,  since  MM. 
Devilliers  and  Regnauld  have  observed  it  to  descend  to  56*39,  would  lead 
to  the  supposition  that  the  cases  under  consideration  were  but  exaggerations 
of  what  ordinarily  occurs,  and  that  the  elimination  of  a  larger  amount  of 
albumen  than  usual  from  the  blood,  be  the  cause  what  it  may,  accounts  foi 


DISEASES     OF     PREGNANCY.  491 

its  evacuation  by  the  urine.  2.  The  albuminuria  of  pregnancy  is  xut  gener- 
ally accompanied  by  the  functional  disorders  and  the  symptoms  to  which  it 
gives  rise  when  connected  with  disease  of  the  kidneys ;  aud  the  dropsy  it- 
self, which  is  almost  constantly  observed  in  the  latter  case,  is  sometimes 
wanting  in  pregnant  women  affected  with  albuminuria,  as  was  twice  ob- 
served by  MM.  Regnauld  and  Devilliers,  as  I  have  myself  witnessed,  and 
as  M.  Blot  found  to  be  the  case  twenty-three  times  out  of  forty-one.  3. 
Lastly,  in  the  majority  of  instances,  it  disappears  immediately  upon  the 
termination  of  the  pregnancy  which  caused  it ;  and  when  we  consider  the 
obstinacy  of  albuminous  nephritis,  it  is  difficult  to  account  for  this  sudden 
disappearance  of  a  disease,  which,  under  other  circumstances  than  the 
puerperal  condition,  so  frequently  has  a  fatal  termination.  On  the  other 
hand,  however,  observation  shows  that  in  almost  all  the  cases  in  which 
women  die  of  the  convulsions  which  too  frequently  complicate  albuminuria, 
the  kidneys  present  the  anatomical  characteristics  of  albuminous  nephritis, 
the  more  or  less  advanced  degrees  of  alteration  appearing  to  correspond 
with  the  duration  of  the  disease  and  the  amount  of  albumen  discharged. 
Many  times  have  I  had  occasion  to  observe  this  fact,  and  fearing  lest  I 
should  interpret  the  alterations  erroneously,  have  almost  uniformly  pre- 
sented the  kidneys  to  the  examination  of  M.  Rayer,  who  generally  recog- 
nized in  them  the  second,  sometimes  the  third,  and  only  once  the  fourth 
degree  of  alteration. 

The  learned  physician  of  La  Charite  considers  the  more  frequent  occur- 
rence of  the  anatomo-pathological  characters  of  the  second  degree  of  the 
disease  to  be  due  solely  to  the  recency  of  the  latter,  and  by  no  means  to  a 
d iilerence  of  nature.  It  is  no  less  the  consequence  of  a  renal  hyperemia, 
which  he  supposes  may  be  caused  in  many  cases  by  compression  of  the 
emulgent  veins  by  the  enlarged  uterus,  and  the  consequent  obstruction  to 
the  return  of  the  venous  blood.  That,  in  simple  cases,  it  generally  dis- 
appears promptly  after  delivery,  is  probably  due  to  the  consequent  cessation 
of  the  congestion  of  the  kidney  which  was  maintained  by  the  pregnancy. 

We  see,  therefore,  that  the  question  is  far  from  being  settled ;  whilst  M. 
Blot,  for  example,  regards  puerperal  albuminuria  as  generally  unconnected 
with  Bright's  disease,  M.  Bach,  of  Strasbourg  (Memoir,  crowned  by  the 
Academy),  thinks  that  it  is  only  sometimes  due  to  albuminous  nephritis,  and 
M.  Imbert  Goubeyre  (Memoir,  crowned  by  the  Academy)  endeavors  to 
prove  that  it  is  always  a  sign  of  Bright's  disease.  Now,  is  it  impossible  to 
throw  a  little  light  upon  this  question,  which  is  still  so  obscure? 

Healthy  urine  contains  no  albumen,  and  the  same  is  true  for  the  healthy 
woman  in  the  puerperal  condition.  Albuminuria,  therefore,  always  indi- 
cates a  pathological  condition  of  which  it  is  the  symptom  ;  for  every  func- 
tional disorder,  whether  temporary  or  persistent,  supposes  a  momentary  or 
prolonged  alteration  of  the  organs  whose  office  it  is  to  accomplish  the  func- 
tion. Therefore,  the  investigation  of  the  causes  of  albuminuria  implies 
that  of  the  general  or  local  affections  which  are  capable  of  producing  it. 
But  lest  we  should  go  astray  in  these  researches,  it  is  very  important  to 
ascertain  a  pi'iorl,  what  are  the  organs  upon  which  the  accomplishment  of 
the  urinary  secretion  devolves.     The  kidney  is  supposed  to  be  exclusively 


-A92  PATHOLOGY     OF      PREGNANCY. 

intrusted  with  this  office,  and  thus  it  happens  that  the  material  explanation 
of  all  the  disorders  of  the  secretion  is  sought  for  in  lesions  of  that  organ. 
Now,  as  M.  Pidous  has  very  judiciously  observed,  the  secretin  n  of  urine  is 
not  confined  to  the  kidney,  since  it  takes  place  previous  to  the  formation  of 
the  latter.  (Uric  acid  and  the  other  elements  of  the  urine  have  been  dis- 
covered in  the  fluid  contained  within  the  allantoid.)  The  process  of  assimi- 
lation, which  is  so  active  in  the  foetus,  can  only  be  understood  by  supposing 
a  contemporaneous  process  of  decomposition.  The  blood  which  flows  to 
the  organ  is  already  charged  with  the  elements  of  urine  which  are  to  be 
separated  from  it  in  the  passage.  The  function  begins  in  all  parts  of  the 
economy  by  this  admixture  of  heterogeneous  elements  with  the  blood,  and 
is  completed  in  the  kidney  by  their  elimination  from  the  circulating  fluid, 
which  is  returned  in  a  purified  condition.  M.  Pidoux  was  therefore  right 
in  saving,  that  the  secretion  of  urine  is  at  once  a  local  and  general  function: 
general,  because  it  commences  everywhere,  and  local,  because  it  ends  in  the 
kidnev.  To  study  the  latter  organ  exclusively,  when  we  wish  to  obtain  a 
physiological  idea  of  the  function,  is  to  neglect  an  important  element;  so, 
also,  in  pathology,  always  to  expect  to  find  the  cause  of  the  disorders  of  the 
urinary  secretion  in  alterations  of  the  kidney,  is  to  overlook  a  multitude  of 
other  causes  which  may  have  a  corresponding  influence.  The  elements  of 
the  blood  conveyed  by  the  renal  artery  exist,  in  health,  in  a  fixed  proportion, 
and  certain  of  them  are  destined  to  be  eliminated  by  the  kidneys.  Now  it 
is  easy  to  understand  that  if  an  alteration  in  the  structure  of  these  organs 
is  capable  of  modifying  both  the  quantity  and  quality  of  the  matters  elimi- 
nated, an  alteration  of  the  fluid,  such,  for  example,  as  the  diminution  or  in- 
crease of  its  solid  or  fluid  parts,  may  also  have  the  same  effect.  Clinical 
observation  and  post-mortem  examination  give  constant  support  to  this  idea  ; 
for  though  we  sometimes  find  a  material  lesion  of  the  kidney  to  which  we 
attribute  the  albuminuria,  we  are  very  frequently  obliged  to  recognize  the 
fact  that  it  is  very  often  absent. 

[In  the  present  state  of  knowledge  in  respect  to  albuminuria  it  cannot  be  regarded 
as  the  symptom  of  any  one  single  lesion,  the  passage  of  albumen  being  due  to 
many  different  causes  upon  the  nature  of  which  great  light  has  been  thrown  by 
physiological  experiment.  The  most  striking  experiment  is  that  of  Claude  Bernard, 
who,  having  injected  a  solution  of  the  white  of  an  egg  into  the  veins  of  an  animal, 
found  that  albumen  soon  made  its  appearance  in  the  urine.  The  same  result  fol- 
lowed the  injection  of  serum  of  blood.  Albuminuria  may  also  be  produced  arti- 
ficially by  feeding  animals  with  albuminous  matters  exclusively-  All  these 
experiments  prove  that  an  excess  of  albumen  in  the  blood  is  always  followed  by 
albuminuria.  A  somewhat  similar  excess  is  found  in  the  blood  of  pregnant  women, 
for,  we  have  here  to  consider  not  the  relative  proportions  of  the  water  and  organic 
matters,  but  rather  the  comparative  relations  of  the  two.  Now  Mr.  Gubler  states 
that  such  a  comparison  shows,  as  a  general  rule,  a  marked  predominance  of  albumen 
as  compared  with  the  corpuscles  (see  page  158).  He  therefore  regards  the  pro- 
portionate superalbuminosis  of  the  blood  as  the  common  determining  cause  of  albu- 
minuria. During  pregnancy,  continues  this  author,  the  mother's  blood  has  to 
supply  the  foetus  with  its  nutritive  materials,  but  only  in  a  soluble  and  diffusible 
form,  inasmuch  as  no  inosculation  exists  between  the  maternal  and  foetal  vessels. 
Albumen  in  its  various  forms  is.  therefore,  required  for  the  nourishment  of  the 
new  being,  and  whilst  this  is  the  case  the  maternal  organism  has  to  provide  for  a 
double  expenditure 


DISEASES    OF    PREGNANCY.  493 

In  consequence  either  of  an  increased  ingestion  or  a  moie  perfect  appropriation 
of  protein  substances,  or  to  both  causes  conjoined,  a  greater  amount  of  albuminous 
matter  is  continually  supplied.  Now,  under  the  changes  impressed  upon  the  func- 
tions, a  bad  state  of  the  economy  or  the  perturbations  produced  by  the  first  efforts, 
so  to  speak,  in  this  novel  direction,  may  cause  the  albumen  to  accumulate  in  pro- 
portions beyond  the  needs  of  the  two  conjoined  organisms. 

In  this  view,  the  albuminuria  of  pregnancy  implies  an  excessive  production  of 
albuminous  matters  in  relation  to  the  requirements  of  both  mother  and  child. 
Sometimes  it  will  be  that  the  former  produces  too  much,  and  sometimes  that  the 
latter  appropriates  too  little;  again,  both  these  conditions  may  concur  to  produce 
the  same  result.  Should  the  children,  when  born,  be  of  the  usual  size  and  weight, 
it  would  be  fair  to  conclude  that  the  albuminuria  resulted  from  disorder  of  the 
maternal  economy  ;  should  they,  however,  be  small  and  puny,  it  would  be  equally 
just  to  suppose  that  their  condition  may  have  caused  the  excess  of  albumen  in  the 
blood  and  its  consequent  filtration  through  the  kidneys.  We  would  add,  as  a  fact 
shown  by  experience,  that  children  born  of  mothers  affected  with  albuminuria 
are  often  of  less  than  the  medium  weight  and  development.  The  remarks  of 
Danyau,  Depaul,  and  Blot  put  the  truth  of  the  latter  statement  beyond  a  doubt. 
(Gubler.) 

In  connection  with  the  superalbuminosis  just  discoursed  of,  we  should  consider 
the  effect  of  the  pressure  of  the  blood  upon  the  walls  of  the  vessels  as  of  no  less 
importance  in  the  etiology  of  the  affection.  If  enough  water  be  thrown  into  the 
vascular  system  to  increase  suddenly  the  mass  of  the  blood  and  produce  a  strong 
vascular  tension,  albumen  is  found  to  escape  immediately  by  the  urine.  A  still 
more  decisive  experiment  is  afforded  by  ligating  the  emulgent  vein.  In  this  case, 
the  sudden  arrest  of  the  venous  circulation  determines  a  progressive  stagnation  in 
the  capillary  vessels  and  albuminuria  results.  The  same  result  is  obtained  if  the 
ligature  be  gradually  tightened,  so  that  entire  interruption  of  the  flow  of  venous 
blood  is  not  produced  for  several  hours  or  even  days.  Whenever,  therefore,  sufficient 
pressure  is  made  by  a  tumor  upon  the  renal  vein  or  vena  cava  inferior  to  slacken 
and  obstruct  the  returning  circulation  in  the  kidney,  the  urine  is  liable  to  contain 
albumen.  This,  M.  Jaccoud  states,  is  the  most  frequent  cause  of  the  albuminuria 
of  pregnancy.  Generally,  indeed,  it  does  not  begin  until  after  the  sixth  month 
of  gestation  (Rosenstein,  Braun),  but  then  everything  conspires  to  produce  con- 
siderable obstruction  of  the  abdominal  circulation;  that  of  the  kidney  is  slackened 
as  well  as  that  of  the  liver  or  spleen  (Virchow),  and  the  pressure  thus  abnormally 
produced  in  the  malpighian  bodies  leads  to  the  passage  of  albumen  into  the  urine. 
This  view,  now  universally  received  (Frerichs,  Braun,  Rosenstein,  Wieger,  Beck- 
mann,  Krassnig,  Brown-Seguard),  is  evidently  not  applicable  to  that  kind  of  albu- 
minuria which  appears  exceptionally  during  the  four  last  months  of  pregnancy. 
At  this  period  it  can  no  longer  be  attributed  to  obstructed  circulation  in  the  renal 
veins,  the  pathological  process  being  entirely  different.     (Jaccoud.) 

Superalbuminosis,  therefore,  on  the  one  hand,  and  great  distention  of  the  vessels 
of  the  kidneys  on  the  other,  afford  a  satisfactory  explanation  of  the  albuminuria  of 
pregnancy ;  but  are  we  to  conclude  that  the  kidneys  themselves  have  nothing  to  do 
with  the  causation  of  the  disease?  Evidently  not,  for  the  albumen  would  remain 
imprisoned  in  the  blood-vessels  indefinitely,  did  not  the  kidney  undergo  such  changes 
ns  would  allow  the  protein  matters  to  pass  through  it,  that  is  to  say,  did  it  not 
become  affected  with  active  congestion  and  certain  transient  parenchymatous 
alterations  which  are  the  instrumental  conditions  of  the  disease.  Co-operative 
circumstances,  such  as  the  impression  of  cold,  might  increase  the  hyperemia  to  the 
state  of  inflammation  properly  so  called,  and  thus  give  rise  to  what  Gubler  has 
termed  secondary  albuminous  nephritis.  In  this  case,  the  albuminuria  is  maintained 
by  the  kidney  itself. 


494  PATHOLOGY    OF    PREGNANCY. 

But  this  is  rrnt  all.  The  kidney  may  also  ho  the  *oat  of  the  iniliivl  phenomena 
jf  the  disease;  which  would  then  he  due  to  a  primitive  albuminous  nephritis. 

To  recapitulate:  the  albuminuria  of  pregnancy  is  produced  by  various  causes, 
the  principal  of  which,  in  our  opinion,  seem  to  proceed  from  and  be  connected  with 
the  three  following  conditions: 

1.  Superalbuminosis. 

2.  Over-distention  of  the  blood-vessels  of  the  kidneys. 

3.  Albuminous  nephritis,  which  may  be  either  primary  or  secondary.] 

This  succession  of  pathological  phenomena  seems  to  me  to  throw  much 
liLrlit  upon  the  etiology  and  nature  of  puerperal  albuminuria,  and  to  recon- 
cile apparently  contradictory  facts  and  opinions.  It  were  certainly  going 
too  far  to  say  that  all  cases  of  albuminuria  during  pregnancy  are  attended 
with  albuminous  nephritis  ;  it  is  an  opposite  exaggeration,  on  the  other 
hand,  to  insist  that  there  very  rarely  exists  a  connection  between  the  albu- 
minous urine  and  the  disease  described  by  Bright.  The  true  statement,  we 
think,  would  be:  that  pregnancy  generally  produces  a  notable  change  in 
the  relative  proportion  of  the  elements  of  the  blood,  which  change  consists 
essentially  in  a  diminution  of  the  solid  constituents,  with  relative  predomi- 
nance of  albumen. 

This  general  alteration  is  of  itself  capable  of  producing  the  elimination 
of  albumen;  but  when  existing  in  a  slight  degree  only,  and  therefore  un- 
equal to  the  production  of  albuminuria,  may  have  its  action  assisted  by  the 
active  or  passive  congestions  to  which  the  kidney  may  he  exposed  during 
pregnancy,  and  especially  during  labor.  Those  simple  hyperemias  of  the 
kidney,  which  are  so  often  seen  after  death,  and  which  are  really  the  first 
degree  of  granular  nephritis,  do  not  appear  to  have  any  other  cause. 

The  marked  influence  which  a  first  pregnancy  appears  to  have  in  the 
production  of  albuminuria  (the  resistance  of  the  Avails  of  the  abdomen 
increase  greatly  the  pressure  sustained  by  the  parts  situated  behind  the 
uterus)  is  thus  explained,  as  also  the  rapidity  with  which  the  albumen 
frequently  disappears  after  labor. 

[According  to  most  authors,  the  presence  of  albumen  in  the  urine  is  almost 
always  coincident  with  diminution  of  urea,  which  would  even  seem  to  lessen  in 
quantity  in  proportion  to  the  ahundance  of  urine.  The  urea  being  imperfectly 
eliminated  by  the  kidneys,  therefore  accumulates  in  the  blood.  For  further  dis- 
cussion  of  this  suhjpct,  see  Urcemia,  at  the  end  of  this  article. 

Let  us  now  examine  the  methods  of  detecting  the  presence  of  albumen  in  the 
urine  and  the  symptomatic  troubles  to  which  its  existence  there  gives  rise. 

Notwithstanding  all  that  ha<  heen  said  respecting  the  appearance  of  alhuminous 
urine,  its  want  of  color,  and  the  frothy  bubbles  which  form  on  its  surface,  it  would 
often  pass  undetected  if  care  were  not  taken  to  examine  it  closely  by  peculiar  pro- 
cesses. Many  chemical  reagents  have  been  proposed  for  its  analysis,  but  heat  and 
nitric  acid  are  almost  the  only  ones  to  be  relied  on. 

The  simplest  process  for  detecting  alhumen  is  as  follows  :  having  drawn  the  urine 
by  a  catheter  in  order  to  avoid  the  inconvenience  of  admixture  with  vaginal  or 
lochial  discharges,  it  should  he  paired  into  a  tube  and  heated  to  the  boiling-point. 
When  ebullition  commences,  should  the  urine  be  albuminous,  it  grows  cloudy,  and 
a  flocculent  coagulum  precipitates.  It  ought,  however,  to  be  understood  that  this 
eoagulum  is  not  a  certain  indication  "f  albumen,  since  alkaline  urine  might  pre- 
cipitate its  earthy  salts.     An  opp  »site  error  might  also  occ  lr,  inasmuch  as  highly 


DISEASES   OP    PREGNANCY.  495 

alkaline  and  at  the  same  time  notably  albuminous  urine  contains  but  a  small  pro- 
portion of  earthy  salts  and  is  not  clouded  by  heat.  In  all  cases,  therefore,  it  is 
indispensably  necessary  first  to  test  the  urine  by  litmus-paper,  and  if  alkaline  to 
acidulate  it  with  a  small  quantity  of  nitric  acid  ;  after  which  it  should  be  subjected 
to  boiling. 

The  testing  by  heat  is  liable  to  another  objection,  to  wit,  that  urine  which  is 
albuminous  but  at  the  same  time  very  acid,  may  not  yield  a  precipitate  by  heat. 
The  resistance  to  coagulation  depends,  in  this  case,  according  to  Gubler,  upon  the 
presence  of  phosphoric  acid.  Here  a  little  nitric  acid,  by  neutralizing  the  influence 
of  the  phosphoric  acid,  restores  to  the  albumen  the  power  of  coagulation  by  heat. 
On  the  other  hand,  a  still  larger  proportion  of  acid  would  precipitate  the  albumeu 
directly,  without  the  assistance  of  an  elevated  temperature. 

Instead  of  having  recourse  to  heat,  albumen  may  be  sought  for  in  urine  by 
allowing  a  few  drops  of  nitric  acid  to  flow  down  the  sides  of  the  glass  containing 
the  fluid.     The  acid  coagulates  the  albumen  and  a  flocculent  precipitate  soon  forms. 

This  method,  unfortunately,  is  not  decisive,  for  the  action  of  nitric  acid  upon 
cold  and  acid  urine  gives  a  precipitate  of  uric  acid  resembling  considerably 
that  of  albumen.  We  may  avoid  deception,  however,  by  Avarming  the  clouded 
fluid,  which  will  resume  its  transparency  as  the  temperature  rises  in  consequence 
of  the  greater  solubility  of  uric  acid  at  high  than  at  low  temperatures. 

All  the  preceding  considerations  show  :  1st,  that  albumen  may  be  supposed  to 
exist  when  it  is  absent;  2d,  that  it  may  be  overlooked  when  present.  The  testing 
for  albumen  is  not  so  easy  as  is  generally  supposed.  Therefore,  it  were  better,  for 
greater  certainty,  to  examine  first  by  boiling  and  then  by  nitric  acid.  All  the 
difficulties  presented  by  the  analysis  have  been  thoroughly  stated  by  Gubler 
(Diclionnaire  Encyclopedique),  whose  work  we  refer  to  without  being  able  to  enter 
at  present  into  greater  detail.] 

The  urine,  in  Bright's  disease,  presents  other  alterations  besides  its  admix- 
ture with  a  certain  proportion  of  albumen.  Thus,  when  submitted  to  micro- 
scopic examination  at  a  certain  period  of  the  disease,  it  is  found  to  contain 
mucous  corpuscles,  scales  of  epithelium  derived  from  the  bladder,  ureters, 
and  pelvis  of  the  kidney,  besides  elongated  cylindrical  bodies  formed  of 
amorphous  fibrin,  in  the  substance  of  which  blood-corpuscles  may  be  ob- 
served, either  singly  or  in  groups.  These  have  been  termed  fibrinous  cylin- 
ders, and  are  regarded  by  Frerich  as  pathognomonic  of  Bright's  disease. 

According  to  some  authors,  all  these  peculiarities  are  observable  in  the 
urine  of  pregnant  women  affected  with  albuminuria;  according  to  others, 
on  the  contrary,  the  fibrinous  cylinders  are  very  rare  in  the  latter  case,  and 
M.  Blot  has  quite  recently  examined  the  urine  of  three  eclamptic  patients 
without  discovering  them. 

I  am  not  prepared  to  decide  upon  this  point,  though  it  seems  to  me  very 
probable  that  this  difference  of  results  is  simply  due  to  the  fact  that,  in  the 
first  case,  the  kidneys  were  diseased,  whilst  in  the  second  the  recent  albumi- 
nuria was  connected  only  with  a  general  alteration  of  the  fluids- 
After  the  indications  afforded  by  examination  of  the  urine,  the  next  most 
frequent  symptom  of  albuminuria  is  general  infiltration  or  anasarca,  which 
must  not  be  confounded  with  bedema  of  the  lower  extremities.  (See  Dropsy 
of  the  Cellular  Tissue.)  The  latter  is  occasioned  simply  by  the  mechanical 
obstruction  of  the  venous  circulation  produced  by  the  pressure  of  the  gravid 
uterus. 


496  PATHOLQGY  OF  PREGNANCY. 

General  infiltration  is  not  so  uniform  an  accompaniment  of  albuminuria  as 
I  thought  formerly.  In  order  to  determine  its  relative  frequency,  it  is 
necessary  not  only  to  examine  the  urine  of  infiltrated  females,  as  was  my 
practice,  but  to  investigate  carefully  the  urine  of  all  pregnant  women,  as 
was  done  by  M.  Blot.  It  will  then  be  discovered  that  many  patients  with 
albuminuria  present  not  a  trace  of  oedema.  M.  Blot  found  it,  we  have  said, 
iu  23  cases  out  of  41. 

It  is  proper  to  observe,  that  this  absence  of  infiltration  is  also  often  noticed 
in  the  ordinary  Bright'a  disease.  By  a  collection  of  observations  with 
autopsies,  derived  from  various  authors,  Frerich  found  that,  of  220  cases  of 
Blight's  disease,  175  were  accompanied  with  cedema,  and  45  were  free 
from  it. 

Nervous  disorders  are  sometimes  attendant  upon  the  anasarca. 

In  the  last  edition  of  this  work  we  stated  that  puerperal  albuminuria  did 
not  usually  give  rise  to  the  symptoms  which  accompany  Bright's  disease. 
This  is  true  for  the  light  cases;  which,  happily,  are  the  most  frequent ;  but 
science  has  progressed,  and  modern  researches  have  proved  that  certain  of 
the  affections  of  the  pregnant  female,  whose  cause  and  nature  were  entirely 
unknown,  coincide  with  albuminuria,  and  very  probably  are,  like  it,  the 
consequence  of  extensive  elimination  of  albumen  from  the  blood.  Thus,  in 
several  cases  of  amaurosis  occurring  during  pregnancy,  MM.  Simpson,  Im- 
bert  Goubeyre,  and  others,  have  detected  albumen  in  the  urine.  The  same 
is  true  of  certain  cases  of  obstinate  headache,  of  lumbar  pains  and  pleuro- 
dynia, of  paralysis  (hemiplegia  or  paraplegia),  (Robert  Johns,  Simpson,  Im- 
bert  Goubeyre),  and  of  contractions,  hemorrhages  (Blot),  &c.  (See  Urcemia, 
and  Paralysis.) 

Now,  M.  Imbert  Goubeyre's  remark  is  very  important,  namely,  that  all 
these  phenomena  are  found  in  the  symptomatology  of  Bright  s  disease,  which 
confirms  the  comparison  that  wre  have  made. 

To  the  symptoms  just  mentioned  we  might  add  eclamptic  convulsions, 
which  are,  happily,  quite  rare,  and  hardly  ever  appear,  except  at  an  ad- 
vanced stage  of  the  disease.  We  shall  treat  of  them  at  length  hereafter. 
(See  Urcemia,  and  Eclampsia.) 

It  is  very  difficult,  not  to  say  impossible,  to  determine  with  certainty  when 
the  albuminuria  commences;  to  do  this,  it  would  be  necessary  to  examine 
daily  the  urine  of  a  large  number  of  women  during  the  entire  period  of 
pregnancy.  Hitherto,  it  has  generally  been  observed  only  during  the  latter 
months.  M.  Bach,  of  Strasbourg,  however,  says  that  he  has  seen  it  at  six 
weeks  in  a  very  nervous  person.  I  once  detected  it  at  four  months  in  a 
greatly  infiltrated  primiparous  female,  who  was  delivered  at  six  months  of 
a  still-born  child,  and  whose  urine  was  slightly  albuminous  eighteen  months 
afterwards,  although  the  infiltration  had  disappeared  since  six  months.  M. 
Cahen  mentions  in  his  thesis  three  cases,  recorded  in  the  fifth  and  sixth 
mouths,  and  M.  Bach  two  others.  Perhaps,  now  that  attention  is  directed 
to  this  point,  such  facts  will  multiply;  but  those  observed  hitherto  have 
almost  always  been  noticed  in  the  latter  stages.  Sometimes  it  appears  only 
at  the  moment  of  delivery,  under  the  influence  of  the  parturient  efforts, 
which  are  well  calculated  to  produce  congestion  of  the  kidneys. 


DISEASES   OF   PREGNANCY.  497 

When  once  begun,  the  progress  of  albuminuria  is  liable  to  great  varia- 
tion ;  sometimes  it  continues  uninterruptedly  until  the  commencement  of 
labor,  and  increases  during  its  continuance;  at  others,  it  varies  greatly  in 
intensity,  and  may  even  cease  completely  for  several  days,  then  reappear, 
and  again  stop  at  very  indefinite  intervals. 

When  it  begins  during  labor  or  shortly  before,  it  often  disappears  a  few 
hours  or  days  after  delivery  ;  but  it  follows  from  the  facts  collected  by  M. 
Imbert  Goubeyre,  that  so  prompt  a  cessation  is  not  as  common  as  I  had 
thought,  and  as  M.  Blot  had  stated.  Though  there  are  cases,  says  M.  Im- 
bert Goubeyre  (memoir  quoted),  in  which  the  albumen  disappears  with 
rapidity,  in  others  it  continues,  and  passes  into  chronic  and  confirmed 
Bright's  disease.  From  a  statement  by  this  author,  it  appears  that,  of  65 
cases  of  puerperal  albuminuria  unaccompanied  with  eclampsia,  21  proved 
fatal  during  pregnancy  and  the  lying-in  ;  and  6  from  the  third  to  the  four- 
teenth month  after  delivery ;  5  cases  became  chronic,  and  were  found  to  be 
still  existent,  two,  eight,  ten,  and  fourteen  months,  and  seven  years  after 
the  labor. 

I  but  just  now  mentioned  a  case  in  which  albumen  was  detected  in  the 
urine  eighteen  months  after  delivery. 

These  differences  appear  to  me  to  be  due  to  the  greater  or  less  intensity 
of  the  disease.  When  the  alteration  of  the  fluids  is  but  slight,  especially 
when  it  has  existed  for  but  a  short  time,  and  occurs  towards  the  end  of  ges- 
tation, or  only  during  the  labor ;  when,  finally,  the  active  or  passive  con- 
gestion of  the  kidneys,  produced  by  obstruction  of  the  venous  circulation, 
has  had  its  influence  in  causing  the  albuminuria,  we  can  understand  how 
the  removal  of  one  of  the  causes,  by  delivery,  may  leave  the  other  inca- 
pable of  sustaining  the  functional  disorder.  But  when  the  alteration  is 
slight,  especially  when  it  dates  back  to  the  middle  or  first  half  of  the  preg- 
nancy, it  may  then  continue  for  a  long  time  after  delivery.  In  these  latter 
cases,  granular  nephritis  is  often  present;  but  I  am  much  inclined  to  believe 
that  sometimes  the  kidney  is  unchanged,  or  very  slightly  altered,  notwith- 
standing the  persistence  of  the  albuminuria. 

In  respect  to  the  prognosis,  the  coexistence  of  an  alteration  of  the  kidney 
is  of  the  highest  importance;  unfortunately,  however,  the  diagnosis  during 
life  of  this  organic  lesion  is  extremely  difficult,  inasmuch  as  none  of  its 
symptoms  are  pathognomonic.  It  would  appear,  however,  from  the  re- 
searches of  M.  Pickard  (thesis,  Strasbourg,  1856),  that  great  light  may  bo 
thrown  upon  the  question  by  analysis  of  the  blood,  sinc2,  when  the  kidneys 
are  diseased,  the  blood  contains  an  amount  of  urea  much  greater  than  in 
any  other  cases  of  albuminuria;  moreover,  the  quantity  of  urea  is  propor- 
tionate to  the  greater  or  less  advanced  degree  of  renal  alteration,  a  very 
small  proportion  of  urea  in  the  blood  generally  coin  ?iding  with  simple  con- 
gestion of  the  kidneys. 

Has  the  albuminuria  any  effect  upon  the  progress  :>f  the  pregnancy,  and 
upon  the  life  and  development  of  the  foetus?  M.  Blot  thinks  thai  it  has 
not,  whilst  MM.  Cahen,  Rayer,  and  some  others,  hold  the  contrary  opinion.- 

I  still  regard  the  view  of  M.  Blot  as  entirely  correct  for  the  slight  cases, 
which  are,  I  repeat,  the  most  common;  but  it  does  not  appear  to  me  well 
32 


498  PATHOLOGY  OF  PREGNANCY 

founded  as  regards  those  complicated  with  anasarca,  or  which  begin  before 
the  latter  half  of  gestation.  I  am  very  much  inclined  to  consider  it  as 
being  then  a  frequent  cause  of  abortion,  of  premature  labor,  and  of  death 
to  the  foetus. 

We  have  noticed  the  views  of  Simpson  and  others  respecting  the  frequent 
occurrence  of  albuminuria  in  numerous  puerperal  disorders.  M.  Blot  con- 
siders it  a  cause  of  hemorrhage.  It  is,  therefore,  as  relates  to  the  prognosis, 
a  sign  which  is  always  calculated  to  excite  solicitude.  As  a  diagnostic  sign 
it  is  certainly  destined  to  reveal  the  nature  and  etiology  of  a  multitude  of 
affections  hitherto  of  very  difficult  explanation;  therefore,  it  is  now  indis- 
pensable, in  obscure  cases,  to  examine  carefully  tbe  urine  of  pregnant  women, 
even  when  unattended  with  dropsy.  It  may  possibly  be  shown  in  the  future 
that  albuminuria  is  a  central  point  towards  which  converge  a  multitude  of 
diseases  of  various  characters,  and  these  researches  may  throw  light  upon 
their  treatment,  which  is  still  so  obscure. 

If  we  have  succeeded  in  showing  that  an  altered  state  of  the  blood  is  the 
principal  cause  of  puerperal  albuminuria,  and  that  this  alteration  consists 
chiefly  in  a  diminution  of  its  solid  constituents,  we  shall  have  no  occasion 
to  insist  strongly  upon  the  advantages  of  a  reparatory  treatment.  Unless 
very  evident  symptoms  of  general  plethora  or  renal  congestion  be  present, 
bleeding  would  be  rather  hurtful  than  useful,  in  a  disease  attended  with  so 
greal  impoverishment  of  the  system;  therefore  a  tonic  medication  should 
be  resorted  to  from  the  outset.  A  good  animal  diet,  assisted  by  the  use  of 
whatever  feiruginous  preparation  will  be  most  readily  supported  by  the 
patient,  ought  evidently  to  form  the  basis  of  the  treatment.  The  prepara- 
tions of  Peruvian  bark,  and  other  bitters,  may  be  added  with  advantage. 

[Vrtrmia. —  Wo  have  just  said  that  albuminuria  is  often  accompanied  by  various 
nervous  disorders  (amaurosis,  paralysis,  eclampsia),  the  production  of  which  it  is 
very  difficult  to  explain  satisfactorily.  It  will  not,  however,  be  forgotten  that 
albuminous  urine  contains  hut  little  urea  (see  page  494),  which  heing  no  longer 
eliminated  by  the  kidneys,  must  necessarily  accumulate  in  the  blood.  This  fact 
is  supposed  to  account  for  the  nervous  disorders  in  question,  by  giving  rise  to  a 
peculiar  poisoning  to  which  the  name  uraemia  is  applied.  We  propose  now  to  state 
the  principal  points  and  successive  phases  of  the  doctrine  of  uraemia,  premising, 
however,  that  it  is  liable  to  numerous  objections. 

Wilson  first,  and  afterwards  llayer,  attributed  the  nervous  complications  of 
albuminuria  to  the  presence  of  urea  in  the  blood.      At  first  accepted  without  limi- 

tation,  this  opinion  was  s i  attacked  in  its  very  foundation.     Cases  were  cited  in 

which  urea  was  present  in  large  amount  in  human  blood  without  being  attended 
by  any  of  the  so-called  uraemic  symptoms.  Finally,  CI.  Bernard,  from  experiments 
made  by  injecting  urea  into  the  blood  of  animals,  came  to  the  conclusion  that  urea 
is  incapable  of  producing  the  nervous  accidents  of  albuminuria.  Thus  Wilson's 
theory  was  ruined. 

Frerichs  came,  for  a  while,  to  the  rescue  of  the  doctrine  of  uraemia  by  explaining 
the  facts  differently.  According  to  him,  urea  is,  of  itself,  innocuous,  the  danger 
arising  from  the  facf  that  it  is  easily  decomposed  in  the  blood,  giving  rise  to  car- 
bonate of  ammonia,  which  really  is  poisonous.  Frerichs'  experiments  appeared  to 
be  decisive.  lie  injected  carbonate  of  ammonia  into  the  veins  of  dogs  in  good 
health,  and  after  a  very  short  time  the  expired  air  contained  carbonate  of  ammonia, 
and  the  animals  were  soon  taken  with  convulsions  and  coma.      The  symptoms  thus 


DISEASES   OF   PREGNANCY.  AU[) 

artificially  piDduced  bore  a  strong  resemblance  to  eclampsia,  and  Frericbs'  position 
6eemed  fol  a  time  to  be  thoroughly  established.  It  was  thus  presented  in  a  favor- 
able light  in  former  editions  of  this  work,  but  since  then  it  has  lost  ground  and 
its  partisans  become  daily  less  numerous.  The  fact  is,  that  the  theory  is  not  free 
from  objections  ;  and  out  of  a  great  number  of  experiments  which  go  to  contravene 
those  of  Frerichs,  I  again  cite  the  opinion  of  Bernard,  which  is  far  from  being 
favorable.  This  celebrated  physiologist  asserts  that  carbonate  of  ammonia  is  almost 
always  present  in  human  blood,  whether  in  health  or  in  disease,  and  the  experi- 
ments which  he  undertook  satisfied  him,  moreover,  that  it  is  far  from  being  pro- 
ductive of  the  terrible  nervous  symptoms  which  have  been  attributed  to  it.  "  If," 
says  the  learned  professor,  "carbonate  of  ammonia  be  injected  in  small  quantity, 
it  produces  no  effect.  When  thrown  in  larger  amount  into  the  blood  of  a  dog.  the 
animal  cried  and  was  extremely  agitated  for  a  considerable  time:  nevertheless  it 
recovered."  From  these  experiments  Bernard  concludes  that  eclampsia  cannot  be 
explained  by  carbonate  of  ammonia.  The  same  opinion  is  given  in  the  excellent 
thesis  for  the  Concours,  of  my  colleague  Dr.  Fournier;  and,  for  my  own  part,  I 
would  say  with  him  that  Frerichs'  doctrine,  ingenious  and  learned  though  it  be, 
will  not  bear  severe  scrutiny.  (Fournier,  These  de  Concours  pour  V Agrijation, 
1863.) 

At  present,  the  position  can  no  longer  be  sustained  that  urjemic  symptoms  are 
due  to  the  presence  in  the  blood  of  any  single  principle,  whether  urea  or  carbonate 
of  ammonia.  Schottin  assumes  that  substances  imperfectly  known  as  yet,  and 
vaguely  styled  extractive  matters,  may  accompany  the  urea,  remain  in  the  blood, 
and  give  rise  to  a  poisoning  which  Gubler  proposed  to  call  urincemia.  This  last 
mode  of  interpreting  the  facts  is  an  approximation,  perhaps,  to  the  truth,  though 
it  is  far  from  proven  that  it  represents  it  precisely. 

"If  the  doctrine  of  uraemia  or  of  urineemia  be  accepted  as  true,  how  shall  the 
nervous  troubles  which  it  produces  be  explained?  Here  come  in  what  have  been 
termed  the  nervous  theories  of  uragmia.  Certain  authors,  as  Traube  and  S£e,  re- 
gard the  nervous  phenomena  of  urasmia  as  somewhat  analogous,  as  respects  the 
intrinsic  mode  of  production,  with  the  pathogenic  process  which  Kusmans,  Tenner, 
and  others  assign  to  epilepsy.  Through  some  change  in  the  blood  an  excitement 
is  produced  of  the  vaso-motor  nerves  and  the  cerebral  arteries.  These  arteries 
contract,  and  there  result  either  oligasmia  of  the  medulla  oblongata  giving  rise  to 
convulsions,  or  the  same  condition  of  the  encephalon  giving  rise  to  coma."  (Four- 
nier, Thhse  de  Concours.) 

In  short,  the  clinical  facts  are  real,  and  all  physicians  have  occasion  to  see  how 
frequently  nervous  troubles  arise  in  the  course  of  an  attack  of  albuminuria.  How 
shall  they  be  explained?  Though  the  question  seem  at  present  to  be  unanswerable, 
I  have  deemed  it  my  duty  to  exhibit  the  present  state  of  knowledge  on  the  subject, 
Should  the  doctrine  of  uraemia  be  false  and  that  of  urinoemia  doubtful,  plausible 
hypotheses  would  still  remain  whereby  to  explain  the  nervous  disorders  compli- 
cating albuminuria.  Other  changes  in  the  blood,  altered  nutrition  of  the  nervous 
tissue  (Gubler),  hyperemia  or  anaemia  of  the  encephalon,  serous  effusions  upon 
the  surface  of  or  in  'the  cavities  of  the  brain  (Rilliet,  Natalis  Guillot),  and  oedema 
of  the  cerebral  substance,  are  all  circumstances  capable  of  explaining  the  convul- 
sive phenomena  and  concomitant  symptoms  observed  in  certain  forms  of  albu- 
minuria.    (Gubler.) 

One  other  difficulty  remains  to  be  mentioned.  What  are  the  nervous  disorders 
observed  in  cases  of  albuminuria?  In  the  first  place  we  would  mention  cephalalgia, 
troubled  vision  and  hearing,  vomiting,  coma  and  eclampsia.  Up  to  this  point  there 
is  no  disagreement,  lint  are  cases  of  paralysis  like  hemiplegia  or  paraplegia  <-ver 
witnessed?  Here  is  a  case  of  controversy  :  Churchill  and  Imbert  Goubeyre  on  the 
one  hand,  admit  that  puerperal   paralyses  are   not    uncommon,   whilst  on   Ue  olhei 


500  PATHOLOGY  OF  PREGNANCY. 

almost  all  pathologists,  Addison,  S6i%  Lasegue,  Fournier,  and  Grisolle,  remars  thai 
paralysis  lias  no  place  amongst  the  nervous  disorders  of  albuminuria.  When  here- 
after we  come  to  study  puerperal  paralysis  and  include  uraemia  in  their  etiology. 
we  shall  not  lose  sight  of  the  difference  of  opinion  upon  this  subject. 

In  short,  various  nervous  affections  occur  in  women  affected  with  albuminuria, 
to  explain  which  the  doctrine  of  uraemia  and  urinaamia  has  been  invoked,  although 
confidence  in  it  has  become  very  much  shaken.  All  our  knowledge  on  the  subject 
is  hypothetical,  and  further  investigation  is  indispensable  to  reduce  it  to  any  cer- 
tainty  ;  therefore,  whenever  we  shall  mention  uraemia  in  explanation  of  any  patho- 
logical condition,  our  reservation  on  the  matter  will  be  brought  to  recollection.] 

§  4.  Dropsy  of  the  Cellular  Tissue. 

Another  affection  of  quite  frequent  occurrence,  and  one  which  is  often 
connected  with  what  accoucheurs  call  plethora,  of  which,  according  to 
Chaussicr,  it  is  a  variety  (serous  plethora),  is  serous  infiltration  of  the  cellular 
tissue.  This  infiltration  begins  in  the  feet,  then  extends  to  the  legs,  thighs, 
genital  parts,  and  sometimes  rising  above  the  lower  extremities,  invades  the 
trunk,  lace,  upper  extremities,  and  is  sometimes  even  accompanied  by  effu- 
sion into  the  great  serous  cavities. 

These  dropsies,  upon  which  MM.  Devilliers  and  Regnauld  have  published 
an  interesting  memoir,  are  by  them  divided  into:  1,  simple  oedemas;  2, 
oedemas  connected  with  affection  of  the  central  organs  of  respiration  and 
circulation;  3,  oedemas  with  albuminuria. 

The  oedema  connected  with  lesions  of  the  organs  of  circulation  generally 
increases  during  pregnancy,  but  this  increase  is  especially  due  to  the  un- 
fortunate influence  which  gestation  has  upon  all  organic  lesions,  and  we 
have  no  occasion  to  speak  of  it  further.  As  regards  the  two  other  species, 
we  think  it  proper,  in  order  to  avoid  repetition,  to  include  them  in  the  same 
description;  for  though  they  have  some  special  characters  upon  which  we 
shall  have  to  insist,  they  resemble  each  other  in  a  great  many  particulars. 

The  causes  of  the  serous  infiltrations  which  occur  during  pregnancy,  may 
be  divided  into  general  and  local.  As  first  in  importance  of  the  general 
causes,  we  must  rank  the  decrease  in  the  proportion  of  albumen;  a  decrease 
which  has  been  discovered  by  all  observers  in  the  blood  of  pregnant  women. 
According  to  M.  Andral,  this  special  alteration  of  the  blood  is  the  only  one 
which  necessarily  produces  dropsy.  The  amount  of  effusion  is  dependent 
upon  the  extent  of  the  alteration,  which,  if  considerable,  is  often  attended 
with  albuminuria. 

Hydraemia,  or  serous  plethora,  which  also  produces  oedema  in  certain 
ehlorotie  patients,  may  also  give  rise  to  the  same  symptom  during  preg- 
nancy, and  assist  in  the  production  of  serous  infiltrations.  When  these 
jreneral  alterations  of  the  economy  are  but  slight,  they  usually  would  be 
unequal  to  the  production  of  oedema,  did  not  the  development  of  the  womb 
add  its  local  action  to  their  own. 

The  pressure  of  the  womb  upon  the  surrounding  parts  from  early  preg- 
nancy, and  the  obstruction  which  it  occasions  to  the  performance  of  the 
functions  of  the  central  organs  of  res]  mat  ion  and  circulation  at  an  advanced 
stage,  when  by  rising  into  the  epigastric  region  it  forces  up  the  diaphragm 
and  thus  diminishes  the  thoracic  cavity,  explain  why  the  oedema  commences 


DISEASES    OF    PREGNANCY.  601 

in  the  lower  extremities,  and  why  it  generally  does  not  extend  until  a  much 
later  period  to  the  trunk  and  upper  extremities. 

Progress  and  Symptoms.— Generally  speaking,  the  oedema  makes  its 
appearance  within  the  last  three  months  of  pregnancy,  especially  when  it 
appears  to  he  due  simply  to  a  mechanical  obstruction  of  the  circulation. 
But  when  it  results  from  one  of  the  general  causes  before  mentioned,  it  may 
commence  with  the  pregnancy,  or  in  the  third  or  fourth  month.  However, 
aj  hydrcemia,  the  diminution  of  the  albumen  of  the  blood,  and  the  albu- 
minuria, are  most  generally  observed  in  the  latter  half  of  gestation,  we  may 
understand  that  the  dropsy  to  which  they  give  rise  should  also  be  more 
2ommon  towards  the  seventh,  eighth,  or  ninth  month. 

The  progress  of  the  cedema  of  pregnancy  is  generally  slow  and  chronic  ; 
sometimes,°however,  it  advances  rapidly  in  a  few  weeks.  Whatever  may  be 
the  case  in  this  respect,  it  generally  begins  by  the  lower  extremities ;  some- 
times affecting  one  of  them,  at  others  both.  At  first  it  is  limited  to  the  feet 
and  neighborhood  of  the  ankles;  sometimes  even  it  never  gets  farther  than 
the  lower  part  of  the  legs,  though  quite  frequently  it  reaches  the  knees,  the 
thighs,  and  external  genital  parts.  Occasionally  it  invades  the  integuments 
of  the  lower  part  of  the  trunk,  and  in  some  rare  cases,  generally  attended 
with  albuminuria,  it  affects  even  the  face  and  hands. 

In  the  early  stages,  while  limited  to  the  lower  part  of  the  legs,  it  dis- 
appears at  night,  in  consequence  of  the  horizontal  position,  and  is  only  well 
marked  towards  the  close  of  the  day.  But  when  the  disease  has  advanced 
farther  it  continues,  whatever  position  the  patient  assumes ;  and  although 
the  horizontal  posture  seems  to  diminish  the  swelling  of  the  legs,  it  it  only 
because  the  infiltrated  fluid  is  displaced  to  the  lower  part  of  the  trunk. 

The  amount  of  fluid  extravasated  varies  between  a  slight  puffiness  and 
the  extreme  swelling  which  makes  standing  and  walking  impossible.  ^  In 
the  latter  case,  the  parts  affected  are  generally  the  seat  of  pain,  of  sensations 
of  pricking,  and  sometimes  of  burning  and  extreme  tension. 

The  cedema  rarely  disappears  before  delivery ;  on  the  contrary,  it  gen- 
erally increases  until  near  the  end  of  pregnancy.  Sometimes,  however,  as 
MM.  Devilliers  and  Regnauld  have  indicated,  it  undergoes  remarkable 
variations.  Thus,  it  may  disappear  entirely  and  finally,  or  it  may  return 
shortly  after ;  sometimes  it  is  observed  to  leave  one  member  and  fix  upon 
the  other,  which  had  been  but  partially  affected.  These  changes  are  doubt- 
less owing  to  mechanical  causes,  the  action  of  which  varies  or  ceases  with 
alterations  in  the  situation  of  the  uterus  (Devilliers  and  Regnauld);  but 
they  certainly  may  also  be  occasioned  by  fluctuations  in  the  albuminuria, 
which  may  be  suspended  for  a  short  time  and  then  reappear,  as  I  have  wit- 
nessed in  one  case  after  labor. 

Terminations.  —  The  dropsy  of  pregnanl  women,  however  caused,  generally 
disappears  quickly  after  labor;  and  in  cases  of  albuminuria,  the  secretion  of 
albumen  often  ceases  with  equal  rapidity. 

Prognosis.  —  If  the  dropsy'be  viewed  as  :i  simple  fact,  independent  of  tin 
complications  which  so  often  attend  and  follow  it,  it  assumes  the  position  of 
a  merely  troublesome  affection  ;  but  to  appreciate  the  prognosis  rightly,  it  is. 
important  to  remember  that  some  authors  regard  the  oedema  as  favoring 


502  PATHOLOGY    OF    PREGNANCY. 

abortion  and  premature  labor.  They  also  suppose  it  to  be  almost  unit  )nnly 
connected  with  the  etiology  of  eclampsia,  and  often  with  the  development 
of  puerperal  levers;  and  finally,  that  sometimes  the  disappearance  of  the 
effusion  alter  delivery  has  been  followed  by  a  frequently  fatal  serous  conges- 
tion of  the  nervous  centres  or  respiratory  organs.  The  facts  related  by  M. 
Lasserre  leave  no  doubt  in  ray  mind  of  the  truth  of  the  latter  proposition. 
li  is  especially  important  to  bear  in  mind,  that  although  these  dangerous 
complications  are  possible  as  a  consequence  of  simple  oedema,  they  have  been 
chiefly  observed  in  cases  of  albuminuria  with  infiltration,  and  consequently 
that  the  presence  of  albumen  in  the  urine  adds  greatly  to  the  gravity  of  the 
prognosis.  Hence  the  interest  which  then  attaches  to  the  examination  of 
the  urine. 

The  treatment  of  the  dropsy  of  pregnant  females  should  be  conducted  with 
the  double  purpose  of  overcoming  the  organic;  cause  which  so  frequently 
produces  the  oedema,  and  to  stimulate  the  absorption  of  the  effused  fluids. 
The  preparations  of  iron  and  a  tonic  regimen  appear  to  me  to  be  especially 
called  for  in  a  disease  which  is  so  frequently  connected  with  hydremia.  The 
presence  of  albumen  in  considerable  quantity,  even  supposing  it  due  to  a 
nephritis,  docs  not  contraindicate  this  treatment.  The  antiphlogistics  recom- 
mended by  some  authors  seem  to  me  likely  to  be  more  hurtful  than  useful ; 
and  unless  the  patient  suffers  very  severe  lumbar  pains,  or  to  the  general 
infiltration  are  superadded  dyspnoea,  palpitations,  extreme  giddiness,  and 
especially  evident  indications  of  uterine  congestion,  threatening  abortion,  I 
should  think  it  right  to  prescribe  bleeding.  Even  under  the  latter  circum- 
stances, I  would  employ  it  less  as  an  antiphlogistic  than  as  a  revulsive,  nor 
would  I  discontinue  the  use  of  the  iron. 

To  assist  the  absorption  of  the  effused  fluids,  mild  laxatives,  diuretics,  and 
dry  frictions  may  be  used.  To  these  may  be  added  vapor-baths,  provided  the 
patient  is  able  to  bear  them  without  danger  of  cerebral  congestion. 

If  the  distention  and  size  of  the  lower  extremities  is  so  great  as  to  make 
walking  impossible  and  cause  great  suffering,  and  if  the  genital  parts  are 
greatly  swollen,  their  disengorgement  may  be  facilitated  by  practising  small 
incisions,  or,  at  least,  a  number  of  punctures,  with  the  lancet  or  a  needle. 
In  several  cases  I  have  derived  benefit  from  keeping  compresses,  saturated 
with  cold  water,  applied  to  the  limbs  for  several  days.  Levret  advises  blisters 
between  the  thighs  and  external  labia,  aided  by  slight  punctures  on  the  feet; 
but  inasmuch  as  the  application  of  blisters  upon  a  highly  oedematous  limb 
U  sometimes  attended  with  serious  consequences,  I  think  it  prudent  to  ab 
stain  from  them. 

§  5.  Ascites. 

We  have  already  stated,  that  dropsy  during  pregnancy  was  so  far  from 
being  limited  to  the  subcutaneous  cellular  tissue,  that  collections  of  fluid  of 
variable  amount  might  take  place  in  the  great  cavities  of  the  body.  The 
effusion  within  the  abdomen  may  occupy  different  locations:  thus,  it  may 
accumulate  within  the  amnion,  and  constitute  dropsy  of  the  amnion;  or 
between  the  membranes  of  the  ovum  and  the  internal  surface  of  the  womb, 
in  which  case  ii  furnishes  the  fluid  that  gives  rise  to  hydrorrhoea  ;  finally,  by 
collecting  within  the  cavity  of  the  peritoneum,  it  forms  a  true  ascites. 


DISEASES    OF    PREGNANCY.  503 

Either  of  these  varieties  of  dropsy  may  occur  separately,  or  two  of  them 
iuay  coexist  in  the  same  female,  as  is  often  the  case  with  ascites  and  hydram- 
uion.     We  shall  treat  first  of  ascites. 

This  affection  sometimes  makes  its  appearance  in  the  first  half  of  the  preg- 
nancy, though  usually  towards  the  fifth  or  sixth  month,  rarely  later.  When 
the  accumulation  begins  very  early,  it  sometimes  progresses  so  rapidly  that 
the  abdomen  is  larger  at  the  fifth  mouth  than  at  the  usual  term  of  ges- 
tation, and  as  the  infiltration  of  the  lower  extremities  generally  keeps  pace 
with  the  effusion  in  the  abdomen,  the  patients  find  it  impossible  either  to 
walk  or  pursue  their  occupations. 

The  progress  of  the  ascites  increases  rapidly ;  the  face  is  puffed  and  livid  ; 
the  abdominal  walls,  much  thickened  by  infiltration,  add  to  the  size  of  the 
belly ;  the  skin  covering  them,  although  distended  and  shining,  sometimes 
has  a  tuberculous  appearance,  as  in  elephantiasis.  The  umbilicus  usually 
forms  a  smooth,  rounded,  translucent  tumor,  of  the  shape  and  size  of  a  hen's 
egg,  at  the  base  of  which  the  umbilical  ring  may  be  felt,  though  it  is  too 
much  distended  to  produce  any  circular  constriction. 

The  greater  labia  share  in  the  general  infiltration,  are  enormously  swollen, 
and  affected  wfith  a  painful  irritation,  produced  by  their  constant  friction 
against  each  other,  and  contact  with  the  urine. 

The  skin  of  the  lower  extremities  is  so  distended  as  to  seem  ready  to  burst 
at  several  points,  and  is  exceedingly  painful. 

The  progressive  accumulation  of  fluid  in  the  cavity  of  the  peritoneum  soon 
obstructs  the  regular  performance  of  the  thoracic  functions ;  the  dyspnoea 
becomes  extreme,  the  respiration  very  short,  wheezing,  and  painful ;  the 
patient  is  obliged  to  remain  seated  night  and  day ;  yet,  notwithstanding  this 
position,  the  ha?matosis  is  so  imperfect  that  she  seems  threatened  with  suffo- 
cation at  every  instant,  and  has  frequent  attacks  of  faintness.  The  suffering 
condition  is  aggravated  by  almost  constant  insomnia,  intense  headache,  ex- 
treme thirst,  and  disgust  for  food. 

Percussion  of  the  abdomen  detects  readily  the  presence  of  a  large  amount 
of  fluid  in  its  cavity,  though  the  fluctuation  is  not  equal  in  all  parts  of  it. 
As  Scarpa  remarks,  it  is  slight  or  absent  in  the  hypogastrium  and  towards 
the  flanks,  is  manifest  near  the  hypochondriac  regions,  and  very  well  marked 
in  the  left  hypochondrium,  near  the  edges  of  the  cartilages  of  the  false  ribs. 

The  enormous  distention  of  the  parietes  of  the  abdomen  frequently  pre- 
vents the  uterus  from  being  felt,  and  its  elevation  determined  with  precision. 
The  motions  of  the  child,  though  generally  obscure,  are,  however,  still  per- 
ceived by  the  mother. 

The  prognosis  of  ascites  complicating  pregnancy  is  grave  in  proportion  as 
it  dates  farther  from  the  term  of  gestation.  When  it  appears  only  in  the 
latter  months,  there  is  every  reason  to  hope  that,  notwithstanding  its  rapid 
progress,  it  will  be  arrested  by  delivery,  before  producing  such  disorders  as 
seriously  to  compromise  the  life  of  the  mother,  and  that,  as  in  the  observa- 
tion of  M.  Prestat,  the  recency  of  the  effusion  will  render  its  absorption  easy 
after  delivery.  But  when  the  ascites  begins  within  the  first  half  of  the  preg- 
nancy, there  is  great  cause  for  fear,  should  it  progress  rapidly,  lest  paracen- 
tesis should  be  demanded  lon^  before  the  ninth  month.     It  were  useless  to 


504  PATHOLOGY  OF    PREGNANCY. 

add,  that  the  prognosis  will  be  far  graver,  if,  as  unfortunately  very  tTten 
happens,  the  ascites  should  coexist  with  dropsy  of  the  amnion.  If,  say9 
Scarpa,  there  should  fortunately  be  no  uterine  dropsy,  the  paracentesis  may 
allow  the  pregnancy  to  progress  favorably  through  its  usual  stages;  but, 
under  the  oppo.-ite  circumstances,  it  almost  always  happens  that  the  womb, 
being  excited  bj  sympathy,  contracts,  and  delivery  follows. 

Treatment.  —  The  general  bleeding,  purgatives,  and  diuretics,  employed 
with  the  design  of  retarding  the  advancement  of  the  disease,  have  not  seemed 
to  influence  its  later  progress,  and  it  is  conceivable  that  a  too  long-continued 
use  of  them  might  be  prejudicial  to  the  pregnancy.  They  should,  therefore, 
be  resorted  to  with  the  greatest  reserve,  and  relinquished  as  soon  as  found 
to  be  unsuccessful. 

When  the  disease  has  increased  to  such  an  extent  as  to  threaten  the  life 
of  the  patient,  it  is  evident  that  the  only  resource  consists  in  the  evacuation 
of  the  fluid.     But  where  should  the  puncture  be  made? 

The  development  of  the  uterus  makes  it  impossible  to  insert  the  trocar  at 
the  place  of  selection  in  ordinary  ascites.  From  the  circumstance  of  the 
fluctuation  being  particularly  well  marked  in  the  left  hypochondrium,  the 
prominence  of  which  was  greatest  near  the  edge  of  the  false  ribs,  Scarpa 
introduced  his  instrument  between  the  uppermost  part  of  the  external 
border  of  the  rectus  muscle  and  the  edge  of  the  false  ribs  in  the  left  hypo- 
chondrium.    The  patient  aborted  two  days  after,  and  recovered. 

George  Langstaff  made  an  incision  two  inches  above  the  umbilicus,  ex- 
posed the  peritoneum,  and  punctured  it  with  a  medium-sized  trocar,  being 
careful  to  introduce  it  but  a  short  distance  so  as  not  to  wound  the  uterus, 
lie  had  thus  given  issue  to  about  ten  pints  of  fluid,  when  the  womb  came  in 
contact  with  the  end  of  the  canula,  interrupting  the  flow,  and  occasioning  so 
much  pain  as  to  oblige  him  to  withdraw  the  instrument.  As  the  patient 
was  unable  to  endure  any  pressure,  he  introduced  a  medium-sized  gum- 
elastic  catheter  by  the  opening,  directing  it  between  the  peritoneum  and  the 
anterior  surface  of  the  uterus.  Peritonitis  followed  eight  hours  after  the  ope 
ration  ;  three  days  subsequently  to  the  operation  she  aborted,  and  three 
weeks  later  she  was  well. 

Finally,  in  a  case  in  which  a  considerable  tumor  existed  at  the  umbilicus, 
Ollivier,  of  Angers,  was  decided  by  the  tension  and  thinness  of  the  skin  at 
the  part  to  make  use  of  the  lancet  simply.  This  instrument  was  introduced 
in  the  same  manner  and  to  the  same  depth,  as  for  bleeding,  at  the  middle 
and  front  part  of  the  tumor,  at  the  distance  of  half  an  inch  from  the  circum- 
ference of  thp  ring.  The  water  flowed  immediately  to  the  amount  of  six- 
teen pounds. 

For  twelve  days,  the  serum  continued  to  flow  by  the  little  wound,  which 
was  closed  hermetically  on  the  thirteenth.  The  patient,  who  had  been  re- 
lieved at  once,  experienced  a  return  of  the  accidents  with  the  fresh  accu- 
mulation of  fluid.  Twenty-eight  days  after  the  first  puncture,  it  became 
necessary  to  repeat  it;  eight  pounds  of  fluid  were  discharged,  and  the  same 
alleviation  followed.  Twelve  days  after  this,  the  woman  was  delivered  of  a 
living,  though  feeble  child,  and  in  fifteen  days  was  discharged  cured. 

This  simple  process,  consisting  of  a  small  puncture  with  the  lancet,  seems 


DISEASES    OF    PREGNANCY.  505 

to  me  preferable  to  Scarpa's  operation  in  the  hypogastriurn.  Tin;  latter 
might,  in  some  cases,  endanger  important  organs,  and  could  only  be  pre- 
ferred on  account  of  the  existence  of  an  old  umbilical  hernia  with  adhesions 
of  the  intestines  to  the  sac.  The  presence  of  this  complication  can  be  readily 
discovered  by  holding  a  candle  behind  the  thin  and  transparent  walls  of  the 
umbilical  tumor,  as  for  the  diagnosis  of  hydrocele,  when  the  opacity  of  the 
exomphalos  will  be  at  once  detected. 

There  is  no  advantage  in  placing  a  foreign  body  in  the  small  opening, 
since  the  flow  of  serum  keeps  the  sides  separated,  and  the  density  and  ex- 
treme thinness  of  the  walls  of  the  tumor  prevent  infiltration  of  the  abdomi- 
nal parietes.  The  observation  of  Langstaff,  above  cited,  as  also  another 
fact  related  by  M.  Danyau,  prove  that  the  introduction  of  a  foreign  body 
exposes  to  peritonitis. 

When  the  pregnancy  has  made  but  slight  progress,  the  only  resource  evi- 
dently consists  in  the  puncture ;  but  when  the  ascites  endangers  the  mother's 
life  only  at  the  eighth  or  ninth  month,  is  it  allowable  to  think  of  premature 
artificial  delivery? 

If  the  uterine  dropsy,  of  which  we  are  about  to  speak  in  detail,  compli- 
cates the  ascites,  and  we  are  able  to  ascertain  that  the  sufferings  of  the 
patient  are  in  good  measure  due  to  the  extreme  size  of  the  uterus,  I  think  the 
tapping  would  be  insufficient,  and  that  the  artificial  induction  of  labor  may 
be  attempted  with  advantage ;  still,  though  common,  the  hydramnion  is  not 
a  necessary  complication,  and  it  seems  to  me  that  ascites  can  very  rarely 
require  premature  delivery. 

In  the  eighth,  and  especially  the  ninth  month,  the  evacuation  of  the  peri- 
toneal fluid  will  afford  sufficiently  lasting  relief  to  enable  the  woman  to 
reach  the  regular  term  of  pregnancy ;  or,  at  least,  it  will  rarely  be  necessary 
to  repeat  the  operation  more  than  once.  Such  was  the  case  with  the  patient 
of  Ollivier.  The  only  fault  to  be  found  with  the  puncture  is  that  of  being 
merely  palliatory,  whilst  it  exhausts  the  strength  if  frequently  repeated. 
But  should  the  relief  afforded  be  such  that  one  or  two  punctures  enable  the 
patient  to  reach  the  end  of  the  ninth  month  with  moderate  suffering,  I  see 
no  reason  for  not  preferring  it  to  premature  delivery,  which  always  places 
the  child  in  unfavorable  conditions. 

ARTICLE  V. 

LESIONS   OF   INNERVATION. 
(J  1.  Eclampsia. 

On  account  of  its  danger  and  the  nature  of  the  convulsions  which  charactei  'izo 
it,  eclampsia  takes  the  foremost  rank  in  the  diseases  of  women.  It  is  liable  to 
appear  suddenly  either  during  pregnancy,  at  the  moment  of  delivery,  or  subsequent 
to  the  removal  of  the  placenta;  it  occurs,  however,  more  frequently  during  labor, 
and  will,  therefore,  be  studied  in  connection  with  the  accidents  of  dystocia.  (Seo 
Dystocia. 

2  2.  Vertigo.    Giddiness.     Lipothymia.    Syncope. 

Those  affections  arc  due  to  various  causes.  Usually  they  seem  to  depend  upon 
great   nervous  susceptibility,  occasioned  by  pregnancy  and   heightened   by  chlorosis; 


506  PATHOLOGY  OF  PREGNANCY. 

less  frequently  they  result  from  plethora,  in  which  case  blood-letting  beco.nes,  ex- 
ceptionally, the  best  method  of  treating  them.  Sometimes,  also,  vertigo  and  giddi- 
ness accompany  albuminuria,  and  precede  eclampsia.  (See  Albuminuria,  and 
Eclampsia.)  In  the  majority  of  cases,  neither  plethora,  albuminuria,  nor  eclampsia 
are  observed  in  connection,  so  that  the  above  named  affections  seem  to  be  due 
simply  to  a  perverted  action  of  the  nervous  system  ;  an  unsatisfactory  explanation, 
but  really  the  only  one  which  can  possibly  be  given] 

Thus  some  delicate,  nervous  women  are  subject  to  faintings,  from  tlie 
most  trifling  cause,  when  they  are  pregnant ;  any  strong  moral  impulses, 
such  as  joy,  or  anger,  and  sometimes  even  an  odor  that  is  a  little  too  pene- 
trating, or  the  sight  of  an  unpleasant  object  or  person,  may  give  rise  to  this 
condition.  ,  Gardien  relates  an  instance,  where  the  simple  movements  of  a 
child  produced  swoonings ;  and  I  have  attended  a  lady  who  fainted  three  or 
four  times  a  week,  during  the  second,  third,  and  fourth  months  of  her  gesta- 
tion, without  any  satisfactory  cause  being  discovered  for  it. 

Ordinarily,  the  syncope  attacks  the  woman  when  standing,  and  she  at 
once  experiences  a  ringing  in  her  ears,  vertigo,  dimness  of  vision,  weakness 
in  the  knees,  and  she  has  scarcely  time  to  sit  down,  before  she  faints  away. 
Some  females,  however,  are  warned  of  the  attack  by  the  occurrence  of 
yawning,  and  a  sensation  of  heat  in  the  precordial  region ;  soon  after,  the 
extremities  become  cold,  the  face  grows  pallid,  and  is  covered  with  a  cold 
sweat ;  the  senses  and  intellectual  faculties  are  almost  lost,  the  pulse  and 
respiration  have  nearly  ceased,  though  a  total  loss  of  the  intelligence  and 
sensibility  is  very  rare.  For  my  own  part,  I  have  never  seen  any  woman  in 
this  latter  state,  since  nearly  all  those  whom  I  have  carefully  questioned  on 
the  subject  have  stated  that  they  had  a  confused  idea  of  what  was  passing 
around  them  ;  and  therefore,  if  there  really  be  any  instances  of  a  complete 
abolition  of  the  faculties,  they  certainly  are  not  so  frequent  as  the  authors 
would  have  us  believe. 

While  the  syncope  lasts,  we  should  employ  the  ordinary  means,  such  as 
ammonia,  vinegar,  cold  water,  &c,  &c.  The  tonics  combined  with  anti- 
spasmodics have  been  recommended  for  its  prevention  :  for  instance,  Van 
Swieten  highly  extols  the  use  of  orange-peel  with  canella,  or  lemon-rind 
and  canella,  in  the  proportion  of  two  or  three  drachms  to  three  pounds  of 
sherry-wine,  of  which  three  or  four  tablespoonfuls  are  to  be  taken  daily. 
Chambon  has  employed  an  infusion  of  peach-blossoms  with  success.  All 
these  nervous  disorders  are  more  alarming  than  serious.  We  have  never 
known  them  to  endanger  the  life  of  the  mother,  or  to  disturb  the  regular 
course  of  gestation. 

The  attacks  of  fainting,  though  generally  short,  are  sometimes  quite  pro- 
longed. In  the  latter  case,  they  are  frequently  accompanied  or  followed  by 
some  hysterical  symptoms,  as  sense  of  oppression,  hypogastric  pain,  constric- 
tion of  the  fauces,  and  sometimes  true  hysterical  convulsions.  In  the  case 
of  a  young  lady,  a  patient  of  M.  Raver's,  these  symptoms  occurred  almost 
every  evening  after  dinner,  during  the  last  three  months  of  her  pregnancy. 
They  had  no  serious  consequence,  unless  a  threatening  of  premature  labor 
towards  the  end  of  the  eighth  month  be  so  regarded,  which,  however, 
yielded  to  a  small  bleeding  and  opiate  injections. 


DISEASES    OF    PREGNANCY.  507 

\  3.  Various  Forms  of  Neuralgia.    Odontalgia. 

Various  forms  of  cephalalgia  and  obstinate  hemicrania  are  oft  3D  observed  during 
pregnancy.  Other  neuralgias  may  also  occur  with  their  usual  syorptoms  in  various 
situations.  The  sensibility  of  the  skin  sometimes  becomes  sc  acute  that  the 
slightest  touch  gives  pain  ;  again  there  may  be  the  sensation  of  intense  heat  in  the 
feet  and  hands,  or  else  an  impression  of  cold  which  nothing  will  remove.  (Jacque- 
mier.)  '1'he  walls  of  the  abdomen  are  often  affected  with  neuralgic  pains,  which 
will  be  studied  hereafter  in  an  article  devoted  to  the  subject.  (See  Abdominal 
Pains.) 

Odontalgia  is  the  most  common  of  all  the  neuralgias  of  pregnant  women.  The 
lower  jaw  is  the  one  usually  affected,  the  pain  sometimes  invading  one  side,  some- 
times both  sides  together.  It  usually  occurs  during  the  first  half  of  gestation,  not 
unfrequently  commencing  shortly  after  conception,  of  which  it  is  sometimes  the 
first  sign.     It  commonly  ceases  from  the  fourth  to  the  sixth  month. 

It  were  not  exactly  correct  to  say  that  every  case  of  odontalgia  is  a  true 
neuralgia,  inasmuch  as  it  is  often  occasioned  by  a  carious  tooth.  It  therefore 
becomes  necessary,  in  view  of  treatment,  to  make  a  correct  diagnosis,  and  in  order 
to  do  so,  to  give  the  mouth  a  very  careful  examination.     (Churchill.) 

Mauriceau  considered  bleeding  the  best  remedy  for  the  toothache  of  pregnant 
women,  yet  it  is  a  measure  by  no  means  certain,  and  in  some  cases  entirely  inad- 
missible. It  is  recommended  to  guard  against  constipation  by  the  use  of  mild 
purgatives  taken  at  short  intervals,  and  as  local  applications,  the  use  of  gargles 
containing  opium,  and  plasters  of  opium  and  hyoscyamus.  Internally,  some  of  the 
preparations  recommended  for  facial  neuralgias  may  be  tried  ;  such  as  pills  of 
eynoglossus  or  Meglin's  pills.  Should  the  paroxysms  and  remissions  be  well 
marked,  and  more  especially  should  there  be  an  actual  intermission,  the  best  effects 
might  be  anticipated  from  the  use  of  quinine.  No  active  measures  should  be 
resorted  to  unless  the  pain  be  very  great,  depriving  the  patient  of  sleep  and  render- 
ing mastication  almost  impossible,  for  the  contact  of  foreign  bodies  with  the  teeth 
is  sometimes  insupportable.  (Jacquemier.)  Capuron  says  that  toothaches  which 
had  resisted  all  kinds  of  remedies  have  been  known  to  subside  spontaneously  about 
the  third  or  fourth  month  of  gestation. 

Should  the  gums  be  inflamed,  one  or  more  leeches  might  be  applied.  If  the 
trouble  is  occasioned  by  a  carious  tooth,  efforts  should  be  made  to  relieve  it  by  the 
measures  commonly  employed,  the  best  being  cauterization  of  the  offending  tooth. 
As  most  authors  think  that  extraction  might  cause  abortion,  it  would  be  well  to 
advise  patients  not  to  undergo  the  operation. 

§  4.  Paralysis. 

Pregnant  women  are  not  exempt  from  the  causes  which  produce  paralysis  under 
ordinary  circumstances,  but  are  even  more  liable  thereto  than  other  females  of 
i heir  age.  That  such  is  the  fact  the  recent  researches  of  Fleetwood  Churchill  and 
Imbert-Gourbeyre  have  established  beyond  a  doubt. 

Churchill  reports  34  cases  of  paralysis  derived  from  various  authors  or  observed 
by  himself.  In  22  of  them,  the  attack  occurred  during  pregnancy,  and  in  the 
remaining  12,  either  during  or  after  labor.  The  location  of  the  paralysis  is  noted 
as  follows:  17  cases  of  complete  hemiplegia  and  1  in  which  it  was  partial;  4  of 
paraplegia,  in  2  of  which  but  one  leg  was  paralyzed;  6  of  facial  paralysis,  3  of 
amaurosis,  and  3  of  deafness  ;  in  some  of  the  latter  cases,  however,  the  local  affec- 
tion was  connected  with  hemiplegia.     Of  these  34  cases,  4  were  fatal. 

Of  the  22  cases  occurring  during  pregnancy  there  were  12  of  hemiplegia,  1  of 
paraplegia,  4  of  facial  paralysis,  2  of  amaurosis,  and  3  of  deafness,  Analysis  of 
these  cases  shows  no  regularity  in  regard  to  the  period  .,f  gestation  at  which  the 
attack  occurred,  though  it  seems  thai  the  patients  were  inure  liable  to  Lhe  affection 


508  PATHOLOGY    OF    PREGNANCY. 

during  the  latter  months.  Must  of  them  recovered  before  or  after  delivery,  tlioiign 
somo  continued  to  be  affected  for  a  considerable  time.  But  one  case  was  fatal,  and 
in  this  it  was  evident  that  the  result  was  due  to  a  disease  of  the  brain  antecedent  to 
the  pregnancy  rather  than  to  the  paralysis  which  had  increased  during  the  latter  ; 
so  that  this  single  case  by  no  means  invalidates  the  conclusion  as  to  the  relatively 
trivial  character  of  these  attacks  during  pregnancy. 

It  is  often  very  difficult  to  determine  precisely  the  influence  which  pregnancy 
may  have  in  the  production  of  the  paralysis.  In  our  brief  exposition  of  the  state 
of  knowledge  ou  the  subject,  we  shall  have  in  view  only  such  cases  as  occur  during 
pregnancy,  and  thus  endeavor  to  avoid  being  led  off  into  the  general  subject  of 
internal  pathology. 

The  causes  of  puerperal  paralysis  are  various  ;  in  the  first  place  we  would  men- 
tion cerebral  apoplexy,  which  is  not  very  uncommon  in  pregnant  women.  Meniere 
reports  in  his  excellent  treatise  several  cases  of  the  kind,  and,  at  a  later  date, 
M.  P.  Dubois,  whilst  discussing  the  subject  in  a  clinical  lecture,  came  to  the  con- 
clusion that  the  frequency  of  its  occurrence  proves  the  existence  of  some  connection 
between  it  and  the  pregnant  condition.  How  then  shall  the  connection  be  ex- 
plained? By  plethora  or  hypertrophy  of  the  heart?  Both  these  views  could 
doubtless  be  well  defended,  but  M.  Imbert-Gourbeyre  believes  that  the  apoplexy  is 
due  to  albuminuria,  which  is  well  known  to  be  common  during  gestation.  He  cites 
in  support  of  his  view  several  cases  of  Bright's  disease  which  terminated  in  cere- 
bral hemorrhage,  and  calls  to  mind  that  it  is  by  no  means  a  rare  attendant  upon 
eclampsia.  More  well  observed  cases  are  necessary  to  enable  us  to  determine  con 
clusively  the  value  of  this  opinion, 

According  to  Churchill  and  Imbert-Gourbeyre,  urcemia  is  almost  the  only  cause 
of  puerperal  paralyses,  such  as  amaurosis,  deafness,  and  hemiplegia.  As  regards 
amaurosis  and  deafness,  we  freely  accept  their  opinion,  but  have  some  doubt  as 
regards  hemiplegia.  Most  authors,  in  fact,  think  that  uraemia  never  occasions 
either  hemiplegia  or  paraplegia  (see  Urcemia),  but  however  this  may  be.  the  so- 
called  uraemie  paralyses  sometimes  accompany  an  attack  of  eclampsia  or  else  are 
preceded  by  it. 

After  cerebral  hemorrhage  and  uraemia,  anaemia  deserves  to  be  mentioned,  as  also 
hysteria,  a  reflex  action  whose  point  of  departure  is  located  in  the  uterus,  but  whose 
influence  extends  to  the  spinal  marrow;  —  rheumatism,  etc.,  may  also  be  noted  as 
causes. 

We  have  thus  endeavored  to  show  that  the  causes  of  puerperal  paralyses  are 
both  numerous  and  variable,  so  that  it  will  be  evident  that  the  prognosis  and 
treatment  will  have  to  be  modified  in  the  different  cases.  The  ordinary  rules  of 
pathology  must  serve  as  a  guide  in  the  course  of  medication  to  be  followed. 

1.  Amaurosis,  — which  is  of  common  occurrence  in  cases  of  albuminuria. 

It  varies  in  degree  from  the  slightest  amblyopia  to  perfect  blindness.  It  usually 
affects  both  eyes,  though  Imbert-Gourbeyre  says  that  he  has  known  but  one  eye 
to  be  involved.  Though  generally  of  short  duration,  it  may  sometimes  become 
permanent  and  incurable.  It  may  also  be  the  first  symptom  to  call  the  attention 
of  the  physician  to  the  possible  existence  of  albuminuria,  and  is  therefore  of  the 
greatest  value  as  a  premonitory  symptom  in  the  diagnosis  of  eclampsia  (see 
Eclampsia).  It  may  make  its  appearance  before,  during,  and  after  labor,  and 
recur  in  several  successive  pregnancies.  If  the  eyes  be  examined  with  the  ophthal- 
moscope, the  retina  will  sometimes  appear  to  be  healthy,  whilst  at  others  a  fatty 
alteration  will  be  observed  or  an  effusion  of  blood;  regard  will  be  had  to  the  lattei 
In  the  formation  of  a  prognosis. 

2.  Deafness.  —  Puerperal  deafness  is  less  frequent  than  amaurosis,  and  like  it  is 
connected  with  albuminuria  and  caused  by  urajmia.  The  deafness  is  generally 
imperfect    and  almost    always  preceded    by  roaring  in  the  ears.       Like  amaurosis,   it 


DISEASES    OF    PREGNANCY.  509 

may  be  intermittent,  permanent,  periodical,  single  or  bilateral;  may  change  into 
exaltation  of  the  sense  of  hearing,  be  connected  with  other  symptoms  of  albuminuria, 
or  exist  alone,  although  it  accompanies  amaurosis  as  it  were  by  preference.  We 
shall  learn  hereafter  (see  Eclampsia),  that  buzzing  in  the  ears  and  deafness  often 
precede  and  announce  an  attack  of  eclampsia  (Imbert-Gourbeyre.) 

3.  Facial  Paralysis.  —  In  connection  with  amaurosis  and  deafness  may  be 
wlaced  paralysis  of  the  third  and  seventh  pairs  of  nerves  —  although  it  is  much  less 
frequent. 

4.  Hemiplegia.  —  Hemiplegia  during  pregnancy  is  of  common  occurrence,  and  M. 
Imbert-Gourbeyre  has  reported  a  large  number  of  cases  in  his  memoir.  Sometimes 
it  is  caused  by  cerebral  apoplexy;  at  others,  no  lesion  of  the  nervous  centres  is  dis- 
coverable at  the  autopsy,  whilst  the  numerous  examples  of  rapid  and  permanent 
recovery  seem  to  prove  that  there  could  have  been  no  grave  lesion  of  the  brain  or 
spinal  marrow.  Albuminuria  alone  and  often  eclampsia  have  been  observed  with 
hemiplegia,  so  that  Imbert-Gourbeyre  feels  no  hesitation  in  saying  that  uraemia  is 
the  usual  cause  of  this  form  of  paralysis.  As  has  been  said,  we  do  not  partake 
wholly  of  this  view  (see  Uraemia). 

Hemiplegia  may  sometimes  also  be  caused  by  anaemia,  as  shown  by  the  following 
case:  A  young  lady  had,  during  the  early  months  of  her  pregnancy,  an  imperfect 
hemiplegia  characterized  only  by  weakness  and  numbness.  The  symptoms  were 
of  short  duration  and  recovery  rapid  and  complete.  In  the  absence  of  any  other 
appreciable  cause,  the  affection  seemed  to  be  due  to  a  well-marked  chlorotic  condition. 

Paralyses  are  not  rare  in  hysterical  women.  There  is  nothing  to  prove  that 
pregnant  females  enjoy  any  immunity  in  this  respect,  so  that  should  any  of  the 
symptoms  peculiar  to  hysteria  exhibit  themselves,  it  would  be  reasonable  to  attri- 
bute the  paralysis  to  the  pre-existing  neurosis.  In  some  patients  even,  the  hysteria 
may  appear  for  the  first  time  during  pregnancy  and  be  attended  by  various 
paralyses.  It  ought,  however,  to  be  noted  that  hemiplegia  is  rarely  dependent 
upon  hysteria. 

Finally,  when  no  cause  can  be  discovered,  we  sij  in  order  to  conceal  our  igno- 
rance, that  the  paralysis  is  essential. 

5.  Paraplegia.  —  Beside  the  usual  causes  of  paraplegia,  and  independently  of  all 
those  above  noted,  this  paralysis  may  be  occasioned  by  pressure  of  the  foetal  head 
upon  the  nerves  of  the  pelvic  cavity  or  by  reflex  action.  Paraplegia  from  pressure 
upon  the  nerves  by  the  head  ought  to  be  rare  during  pregnancy  ;  it  has  been  more 
commonly  witnessed  during  labor  and  after  delivery,  especially  when  the  labor  has 
been  severe  or  attended  with  hemorrhage  ;  we  have  nothing  further  to  say  in  regard 
to  this  cause. 

It  is  acknowledged,  as  stated,  that  paraplegia  may  be  caused  by  reflex  action  ; 
but  how,  in  these  cases,  can  its  production  be  explained?  How  can  a  partial  ex- 
citement of  the  uterus  so  react  upon  the  spinal  marrow  as  to  suspend  its  functions? 
Without  pausing  before  the  various  theories  proposed  by  modern  physiologists,  we 
would  say  that,  according  to  M.  Jaccoud  who  wrote  a  remarkable  work  upon  the 
subject,  paralysis  is  occasioned  by  exhaustion  of  the  nervous  system,  and  that 
numerous  experiments  upon  animals  tend,  at  least,  to  prove  the  correctness  of  his 
view:  "A  long  continued,  abnormal,  excitement  is  transmitted  to  the  spinal  cord 
by  the  uterine  nerves:  after  a  longer  or  shorter  time  it  exhausts  the  excitability 
peculiar  to  the  corresponding  region  of  the  organ,  and  the  inertia  of  these  nervous 
elements  under  the  action  of  the  brain  closes  the  avenues  by  which  the  motor 
impulse  is  transmitted;  as  a  necessary  consequence  of  this  state  of  things  there 
results  paralysis  of  all  parts  situated  below  the  affected  points." 

The  following  case  of  Echeveiria's,  which  the  author  and  others  after  his  example 
have  given  as  a  type  of  the  so-called  reflex  paraplegia  is,  to  my  mind,  an  absolute 
demonstration  of  the  theory  just  stated,  —  allowing  the  finger  to  be  laid,  as  it  were. 


olO  PATHOLOGY  OF  PREGNANCY. 

upon  the  pathological  mechanism  of  the  paralytic  affection.  A  woman  who  had 
miscarried  three  times,  continued  to  suffer  after  the  last  one  severe  pain  in  the 
hypogastriutn  accompanied  by  a  slight  metrorrhagia.  Seventeen  days  after  *hf 
abortion  the  uterus  was  found  to  be,  anteverted  ;  it  was  soft  and  voluminous,  rising 
an  inch  above  the  pubis;  the  neck  was  sensitive,  bled  easily,  and  admitted  the 
finger;   the  anterior  lip  was  covered  by  a  painful  ulcer  of  a  violet-red  color. 

Having  determined  these  facts,  Echeverria,  with  the  double  object  of  exciting 
the  contraction  of  the  uterus  and  hastening  the  cicatrization  of  the  ulcer,  had  re- 
course to  electricity  by  placing  one  pole  of  the  apparatus  upon  the  pubis,  the  other 
in  the  orifice  of  the  cervix,  and  then  transmitting  a  current  of  low  power.  In- 
stantly violent  pain  was  experienced  in  the  womb,  loins,  and  lower  extremities, 
which  were  seized  with  convulsive  tremors.  The  current  was  immediately  sus- 
pended, when  it  was  found  that  in  place  of  the  convulsion  there  was  complete 
paraplegia  which  lasted  for  fourteen  hours  (Jaccoud).  Is  it  not  evident  that  we 
have  here  a  case  in  which  extreme  excitement  exhausted  the  irritability  of  the 
spinal  cord?  Loss  of  motion  resulting  and  continuing  until  the  functions  of  the 
nervous  centre  had  been  restored  by  adequate  repose. 

The  causes  of  paraplegia  may  be  various  and  combined,  of  which  the  following 
case  is  an  example.  A  young  primiparous  lady,  of  extremely  lymphatic  tempera- 
ment and  affected  with  general  oedema,  had  a  tedious  labor  requiring  the  use  of 
the  forceps.  Extensive  laceration  of  the  perineum  occurred,  and  profuse  hemor- 
rhage attended  the  delivery  of  the  placenta.  The  lying-in  was  also  complicated  by 
a  double  phlegmasia  alba  dolens,  pleuritic  effusion,  and  ascites.  I  attended  this 
patient  with  my  friend  Dr.  Siredey,  now  hospital  physician,  and  we  assured  our- 
selves at  various  times  that  the  urine  contained  no  albumen.  When  convalescence 
was  established,  it  was  found  on  getting  the  patient  up  that  she  had  paraplegia. 
For  several  months  she  was  unable  to  stand,  but  the  power  of  motion  gradually 
returned  until  at  length  walking  was  possible  with  the  assistance  of  a  cane.  Whilst 
this  improvement  was  in  progress  the  paraplegia  suddenly  became  complete,  the 
aggravation  being  afterward  found  to  have  coincided  with  the  time  of  her  becoming 
again  pregnant;  and  throughout  the  gestation  no  improvement  took  place.  During 
labor  the  limbs  were  thrown  wildly  about  in  a  way  which  the  patient  would  have 
been  incapable  of  doing  by  any  exertion  of  her  will.  After  delivery  the  power 
of  motion  was  again  wanting.  The  paraplegia  continued  for  several  months  with- 
out much  amelioration,  but  finally  disappeared  under  the  use  of  strychnine  and 
electricity,  the  recovery  having  been  now  for  a  long  time  perfect.  In  this  case, 
thus  briefly  related,  it  would  be  reasonable  to  refer  the  beginning  of  the  paralysis 
either  to  pressure  by  the  head  of  the  child  during  the  first  labor,  or  to  the  hemor- 
rhage attending  the  delivery  of  the  placenta  ;  but  how  shall  we  explain  the  recur- 
rence  of  the  affection  during  the  next  pregnancy?  In  my  opinion,  the  cause  of  the 
new  phase  of  the  disease  must  be  regarded  as  an  instance  of  reflex  action.] 

§  5.  Intellectual  Disorders.     Insanity. 

Those  physicians  who  may  be  willing  to  admit  the  truth  of  the  analogy 
which  we  have  endeavored  to  establish  between  the  sympathetic  disorders 
of  pregnancy,  and  those  observed  in  young  girls  suffering  from  difficult  or 
irregular  menstruation  (p.  462),  will  readily  understand  the  functional  aber- 
rntions  of  the  intellectual  and  sensorial  faculties  so  often  observed  in  preg- 
nant women. 

The  pre-existing  alterations  of  certain  organs  of  the  senses  are  sometimes 
very  happily  modified  by  the  occurrence  of  pregnancy.  A  young  woman, 
whose  imperfect  vision  bad  obliged  her  to  use  specta<  les  from  childhood, 
found  her  sight  so  much  improved  immediately  after  the  beginning  of  preg- 


DISEASES    OF    PREGNANCY.  511 

nancy  as  no  longer  to  have  need  of  glasses.  (Obs.  de  Salmat,  Cent.  III. 
Obs.  27.) 

At  other  times  there  is  greater  or  less  disturbance  of  the  affective  and 
intellectual  faculties.  I  knew  a  young  lady  pregnant  for  the  first  time, 
whose  former  love  for  her  husband  was  replaced  by  an  antipathy  which  she 
was  barely  able  to  overcome.  Another  young  woman,  when  five  months 
gone,  was  suddenly  seized  with  such  an  aversion  for  her  apartment,  that 
after  many  fruitless  efforts,  and  notwithstanding  all  the  force  of  her  reason, 
she  had  to  be  left  in  the  country  for  the  remainder  of  her  pregnancy. 

Some  exhibit  a  peculiar  tendency  to  sadness,  which  is  mentioned  bv 
Burns,  and  of  which  I  have  observed  two  cases.  Certain  individuals,  who 
are  usually  of  a  gay  disposition,  suddenly  become  sad  and  morose;  refuse  all 
the  enjoyments  tendered  to  them,  and  entertain  the  belief  that  they  will  not 
survive  their  labor,  with  a  tenacity  that  nothing  can  overcome.  A  young 
American  lady,  recommended  to  my  care  by  M.  Rayer,  exhibited  a  profound 
melancholy  for  the  last  six  weeks  of  her  pregnancy.  Although  surrounded 
by  her  family,  she  declined  all  the  pleasures  of  the  capital.  She  wept 
unceasingly  over  her  inevitable  end,  which  was  so  near  at  hand,  and  was 
constantly  expressing  her  distress  at  being  obliged  to  leave  all  whom  she 
loved.  She  had  a  happy  labor,  and  from  the  next  day  her  usual  gayety 
was  resumed. 

[Disorders  of  intelligence  may  proceed  even  to  insanity;  although  this  form  is 
more  common  with  newly-delivered  females  than  with  pregnant  women.  Marce's 
excellent  book,  which  shall  be  our  guide  in  the  preparation  of  this  article,  gives  as 
the  result  of  several  collections  of  statistics,  that  of  310  cases  of  puerperal  insanity 
27  came  on  during  pregnancy,  180  after  delivery,  and  103  during  lactation. 

Puerperal  insanity  may  date  from  the  time  of  conception,  or  may  appear  during 
the  course  of  gestation.  In  19  of  Marce's  cases  it  commenced  with  conception 
eight  times,  and  in  the  remaining  eleven  during  pregnancy.  It  began  three  times 
in  the  third  month,  once  in  the  fourth  month,  three  times  in  the  sixth  month,  twice 
in  the  seventh  month,  and  twice  at  times  which  could  not  be  clearly  ascertained. 
Melancholy  seems  to  be  the  most  common  form  of  this  insanity.  Analysis  of  the 
above-mentioned  19  cases  shows  that  the  duration  of  the  disease  is  very  variable. 
Seven  times  the  recovery  dated  from  delivery  ;  twice  only  did  it  occur  during  the 
course  of  gestation  ;  nine  times  the  disease  continued,  or  else  did  not  subside  until 
long  after  delivery  ;  finally,  in  one  ca>e,  the  delirium  was  exasperated  by  deliverv. 
and  death  occurred  shortly  after.  The  physician  ought,  therefore,  to  be  very  guarded 
in  his  statements  when  questioned  in  regard  to  the  probable  result.  It  is  well 
also  to  know  that  when  a  woman  becomes  insane  during  gestation,  there  is  reason 
to  fear  a  recurrence,  should  she  again  become  pregnant. 

Montgomery  mentions  the  case  of  a  woman  who  became  insane  at  the  com- 
mencement of  three  successive  pregnancies.  In  another  case,  the  derangement 
recurred  in  eight  pregnancies,  and  ceased  only  after  delivery.  By  a  curious 
anomaly,  however,  it  happens  that  some  women  suffer  from  this  affection  in  one  of 
their  pregnancies  only. 

Hitherto  we  have  studied  the  influence  of  pregnancy  as  productive  of  mental 
alienation;  but  there  remains  another  question,  the  discussion  of  which  will  not 
be  devoid  of  interest,  to  wit:  What  are  the  effects  of  pregnancy  occurring  in  a 
woman  who  is  already  insane?  In  regard  to  this,  Esquirol  says,  "Pregnancy, 
labor,  and  lactation  are  sometimes  used  by  nature  as  a  means  of  curing  insanity, 
though,   in   my   opinion,   this   result   is  rare."      Almost  always,   indeed,   pregnancy 


512  PATHOLOGY    OF    PREGNANCY. 

gives  to  mental  alienation  a  character  of  extreme  gravity,  either  as  regards  its  form 
or  its  duration.  It  is  evident,  therefore,  that  the  practice  of  some  physicians  who 
recommend  pregnancy  for  insane  women  cannot  be  too  strongly  censured. 

Labor  itself,  in  its  last  stages,  ''specially  when  the  pains  are  extremely  severe, 
may  occasion  disorder  of  the  intellectual  faculties.  All  accoucheurs,  indeed,  have 
described  the  excitement  of  mind  which  occurs  under  these  circumstances,  arid 
which  in  some  rare  cases  assumes  the  form  of  maniacal  delirium.  To  the  examples 
already  noted  on  page  300,  we  add  the  following.  A  woman  in  the  hospital  of  the 
Clinique  was  suddenly,  when  near  the  termination  of  her  labor,  afflicted  with  a 
complete  hallucination  ;  she  saw  a  spectre  at  the  foot  of  her  bed,  endeavoring  to 
injure  her,  and  which  she  made  strong  efforts  to  drive  away.  The  illusion  lasted 
hardly  two  minutes  before  her  mind  became  perfectly  sane.  The  transitory  in 
sanity  occurring  thus  during  labor  is  doubtless  caused  by  the  excessive  pain. 
Notwithstanding  its  apparent  gravity,  it  is  rarely  followed  by  serious  consequences 
if  care  be  taken,  by  sufficient  watchfulness,  to  prevent  the  lamentable  acts  to  which 
the  patients  might  be  impelled.  It  subsides  spontaneously,  and  very  rarely  passes 
into  long-continued  mania. 

The  part  of  the  physician,  in  these  cases,  is  easily  pointed  out.  Generally  every- 
thing will  be  left  to  nature  ;  but  should  the  labor  last  too  long,  delivery  should  be 
effected  by  the  forceps.  Blood-letting  at  a  later  period,  should  it  be  indicated  by 
the  signs  of  plethora,  antispasmodics  and  judicious  expectant  conduct,  will  suffice 
for  the  successful  management  of  an  occurrence  which  in  itself  presents  but  little 
gravity. 

There  remain  a  few  observations  to  be  made  upon  the  subject  of  the  insanity  of 
lying-in  women  and  nurses,  known  as  puerperal  insanity.  As  predisposing  causes  of 
this  affection  may  be  mentioned  inheritance,  numerous  pregnancies,  advanced  age 
of  the  subjects,  previous  attacks  of  insanity,  eclampsia,  and  the  return  of  menstrua- 
tion. Sometimes  the  disease  commences  suddenly,  but  is  often  preceded  by  an 
accelerated  pulse,  heat  of  skin,  dryness  of  tongue,  thirst,  and  the  entire  assemblage 
of  pyretic  symptoms. 

The  various  forms  of  mental  alienation  are  far  from  occurring  with  equal  fre- 
quency under  these  circumstances,  but  may  be  represented  in  the  following  order: 
first,  mania;  secondly,  melancholia  and  partial  insanity. 

The  mania  of  lying-in  women  ends  in  recovery,  incurability,  and,  in  some  rare 
instances,  death.  Of  these,  recovery  is  by  far  the  most  frequent  termination,  and 
may  be  said  to  include  about  two-thirds  of  the  entire  number  of  cases.  Cases  are 
mentioned  in  which  the  affection  subsided  in  less  than  three  days,  though  it  more 
commonly  terminates  within  the  first  month  following  the  commencement  of  the 
attack.  Again,  recovery  may  be  postponed  as  late  as  the  sixth  month,  or  not  take 
place  until  after  one,  two,  or  more  years.  The  prognosis  is  most  favorable  in  mel- 
ancholia and  monomania. 

A  great  variety  of  remedies  have  been  recommended  in  the  treatment  of  puerperal 
mania.  Warm  baths,  purgatives,  and  narcotics  are  the  most  available  at  the  out- 
set. It  is  of  the  greatest  importance  to  watch  the  patients,  and  not  lose  sight  of 
them  for  a  moment.     The  children  should  be  taken  away  (Marc6)  ] 

ARTICLE   VI. 

diseases  of  the  skin. 
§  1.  Itciiin<;. 

The  skin,  during  pregnancy,  is  sometimes  affected  with  extreme  itching 
without  any  appreciable  lesion.  M.  Maslieurat-Lagemart  has  published  a 
remarkable  case  of  a  lady  who,  in  eight  successive  pregnancies,  was  afflicted 


DISEASES     OF     PREGNANCY.  513 

■with  itchings  so  violent  as  to  produce  premature  labors.  On  four  occasions, 
they  began  in  the  sixth  month,  twice  at  eight  months  and  a  half,  and  twice 
in  the  seventh  month.  They  appeared  almost  instantly  over  the  entire 
cutaueous  surface ;  the  legs,  thighs,  genital  parts,  the  whole  trunk,  the  neck, 
face,  scalp,  were  all  affected;  nothing  escaped  but  the  palms  of  the  hands, 
and  even  they  were  invaded  at  a  later  period.  So  severe  were  tliey ,  that 
the  violent  rubbings  of  the  poor  sufferer  excoriated  the  skin.  Hardly  was 
she  delivered  when  they  vanished  entirely.  The  skin  retained  its  natural 
transparency,  color,  and  brightness  throughout.  Simple  and  alkaline  baths, 
ammoniacal  and  camphorated  frictions  to  the  spine,  preparations  of  opium, 
bismuth,  valerian,  hyoscyamus,  belladonna,  and  bleeding,  were  all  employed 
without  advantage. 

Three  cases  of  general  itching  which  I  have  had  occasion  to  treat,  yielded 
quite  promptly  to  alkaline  baths.  (Five  ounces  of  carbonate  of  potash  to 
an  entire  bath. )  Lotions  of  carbolic  acid,  glycerine,  and  water  seldom  fail 
to  relieve  this  condition. 

\l  2.  Pigmentary  Spots.     Pityriasis. 

The  skin  during  pregnancy  often  becomes  affected  -with  yellowish  spots  known 
as  ephelidae,  chloasma,  and  pityriasis  versicolor.  When  they  appear  on  the  forehead, 
cheeks,  and  chin,  they  receive  the  common  name  of  mask.  These  spots  affect  by 
preference  the  face,  especially  the  forehead ;  they  vary  in  size,  are  almost  symmet- 
rical in  form,  and  never  extend  to  the  roots  of  the  hair,  from  which  they  always 
are  separated  by  a  border  of  healthy  skin.  It  would  seem  that  the  action  of  light  is 
one  of  the  principal  conditions  of  their  formation,  and  that  the  shadow  of  the  hair 
is  sufficient  to  arrest  their  progress. 

M.  Hardy,  physician  of  the  Hospital  St.  Louis,  classifies  them  as  ephelides  and 
pityriasis. 

The  ephelides  make  no  projection  from  the  surface,  and  are  attended  by  neither 
itching  nor  desquamation ;  their  examination  would  almost  lead  one  to  say  that  the 
pigmentary  matter  had  left  the  healthy  parts  and  collected  in  the  spots,  on  account 
of  the  apparent  bleaching  of  the  skin  around  them.  They  are  the  result,  simply, 
of  an  accumulation  of  pigment  within  a  circumscribed  space.  Ephelides  often  ap- 
pear in  women  at  the  menstrual  period,  and  more  especially  during  pregnancy  : 
they  usually  vanish  after  delivery,  though,  much  to  the  chagrin  of  those  affected, 
this  does  not  always  happen.  When  they  continue,  a  special  treatment,  having 
for  its  object  the  production  of  a  superficial  inflammation  of  the  skin,  will  often 
prove  successful.  To  effect  this,  M.  Hardy  recommends  frictions  to  be  made  twice 
a  day  with  the  following  lotion: 

R.— AVater,     .  .  .  f^iv. 

Corros.  Sublim.,         ....  gr.  v. 

Sulph.  Zinc,         .....  3SS- 

Acetate  of  Lead,       ....  3ss. 

Alcohol,  .  .  .  .  .  q.  s. 

to  dissolve  the  corrosive  sublimate. 

Slioald  the  lotion  fail,  sulphurous  douches,  especially  with  the  mineral  waters 
of  Luchon  and  Bar6ges,  applied  to  the  affected  parts,  may  be  used  with  advantage. 

Pityriasis  versicolor,  also  termed  hepatic  spots  and  chloasma  of  pregnant  women, 
appear  in  the  form  of  spots  bearing  strong  resemblance  to  the  ephelides.  In  pity- 
riasis, however,  the  spots  project  slightly  from  the  surface  of  the  skin,  and  the  epi- 
dermis becomes  detached  in  the  form  of  little  scales,  either  spontaneously  or  by 
scratching.  They  are  always  accompanied  by  itching,  which  is  generally  slight. 
The  characters  just  mentioned  will  suffice  to  distinguish  pityriasis  versicolor  from 
33 


514  PATHOLOGY     OF     PREGNANCY. 

cpnelides,  in  which  there  are  neither  elevation,  desquamation,  nor  itching.  Pityri- 
asis versicolor  is  a  parasitic  disease,  so  that  the  microscope  affords  another  means 
of  diagnosis  by  exhibiting  the  spores  and  numerous  ramifications  amidst  the  epithe- 
lial Bcales. 

The  pityriasis  of  pregnancy  usually  declines  after  delivery,  though  in  some  ca*cs 
it  remains  and  offers  great  resistance  to  the  treatment  employed. 

The  therapeutic  measures  are  very  simple.  Sulphurous  waters,  by  lotion  or 
douche,  and  ointments  containing  sulphur,  are  often  effectual.  The  above  lotion 
(see  formula)  and  nitric  acid  ointment  produce  similar  results.] 

ARTICLE    VII. 
lesions  of  the  pelvic  articulations. 

§  1.  Relaxation  of  the  Pelvic  Articulations. 

The  question  has  long  been  agitated  whether  the  ligaments  which  unite 
the  bones  of  tbe  pelvis  are  ever  softened,  and  whether  the  articulations  are 
movable.  Ambrose  Pare  himself,  that  great  surgical  luminary,  did  not 
adopt  the  opinion  of  Hippocrates  until  alter  Severin  Pineau  made  a  dissec- 
tion, in  1569,  of  a  woman  recently  delivered,  in  his  presence.  But,  at  the 
present  day,  this  question  is  determined  by  a  very  great  number  of  cases, 
and  it  is  now  generally  admitted  that  a  ramollissement  of  the  symphyses 
actually  occurs  in  most  females  during  gestation. 

This  softening  may  be  and  generally  is  slight;  though  it  may  be  carried 
to  so  great  an  extent  as  to  admit  of  considerable  separation  between  the 
articular  surfaces,  constituting  then  a  true  pathological  alteration.  Hunter, 
Morgagni,  and  some  others,  cite  instances  wdiere  the  relaxation  was  such 
that  t he  pubes  could  be  drawn  more  than  an  inch  apart. 

With  our  present  knowledge  on  the  subject,  it  is  impossible  to  explain  the 
cause  of  this  softening;  for,  when  trifling,  it  generally  escapes  the  notice 
both  of  the  woman  and  her  physician;  but  if  well  marked,  a  separation  of 
the  bones  takes  place  as  just  stated. 

Authors  do  not  agree  as  to  the  manner  in  which  the  separation  is  pro- 
duced; since,  according  to  some,  the  cartilages  are  softened  and  thickened 
by  the  liquids  that  penetrate  them,  acting  like  a  piece  of  prepared  sponge 
placed  between  two  bones  to  absorb  the  effused  fluids;  whilst  others  imagine 
them  to  resemble  the  roots  of  the  ivy,  which  insinuate  themselves  into  the 
little  crevices  between  the  stones  of  a  wall,  and  finally  overturn  it.  Louis 
thinks  they  act  more  like  dry  and  porous  wooden  wedges  placed  in  the 
fissures  of  a  rock,  which,  by  imbibing  moisture,  swell  up  and  ultimately 
split  the  rock,  —  or  like  polypi  in  the  nasal  fossae  and  frontal  or  maxillary 
sinuses. 

M.  Lenoir  supposes  that  a  slight  degree  of  this  relaxation  is  due  simply  to 
infiltration  of  the  pelvic  ligaments  resulting  from  the  pregnant  con- 
dition ;  the  articular  surfaces  are,  therefore,  not  separated,  though  separation 
is  possible  under  the  influence  of  actions  tending  to  produce  it.  In  the  more 
advanced  stages,  he  adds  to  this  softening  a  hypersecretion  of  synovia,  which 
distends  the  articular  cavities,  and  separates  the  bones  that  constitute  them. 
Mobility  in  these  cases  is  great,  and  if  the  joints  be  opened  in  the  dead  body, 
a  viscid  fluid  is  discharged  abundantly,  as  was  once  observed  by  JNIorgagni. 


DISEASES     OF     PREGNANCY.  515 

This  relaxation  may,  according  to  Baudelocque,  oppose  the  spontaneous 
termination  of  the  labor,  by  destroying  the  point  d'appui  which  the  abdo- 
minal muscles  derive  from  the  bones  of  the  pelvis;  and  perhaps,  also,  the 
distress  produced  by  the  engagement  of  the  head,  forces  the  woman  tc  re- 
strain the  pains  as  much  as  possible;  though,  on  the  other  hand,  from  the 
observations  of  Desormeaux,  Smellie,  &c,  we  learn  that  this  circumstance, 
so  far  from  being  a  cause  of  dystocia,  has  actually  permitted  a  spontaneous  de- 
livery in  some  cases  where  the  disproportion  between  the  size  of  the  head  and 
the  dimensions  of  the  pelvis  would  have  otherwise  rendered  it  impossible. 

[The  attention  of  physicians  has,  of  late  years,  been  again  called  to  the  study 
sf  the  relaxation  of  the  pelvic  symphyses  by  a  work  of  M.  Ferdinand"  Martin, 
which  was  soon  followed  by  M.  Danyau's  report.  A  special  article  was  devoted  to 
the  subject  in  the  previous  editions  of  this  work,  so  that  M.  Trousseau  was  wrong 
in  supposing  that  it  had  been  omitted.  (Legons  Cliniques  sur  le  Relachement  des 
Symphyses  du  Bassin,  May,  1865.)  Nevertheless,  as  the  affection  is  still  badly 
understood,  frequent  errors  in  diagnosis  are  the  consequence. 

The  pains  in  the  back  which  many  pregnant  women  suffer,  are  due  simply  to 
relaxation  of  the  symphyses.  To  be  convinced  of  the  fact  it  will  be  sufficient  to 
examine  the  lumbar  region  by  pressure  over  the  sacro-iliac  articulations  when,  if 
they  be  diseased,  decided  pain  will  follow.  The  same  remark  applies  to  the  sym- 
physis pubis,  which  is  often  the  seat  of  the  vague  pains  complained  of  in  the  lower 
part  of  the  abdomen. 

In  all  these  cases  it  is  the  more  easy  to  be  deceived,  as  the  patients,  on  being 
questioned,  are  rarely  able  to  define  clearly  the  seat  of  their  suffering,  and  the  real 
affection  is  overlooked  if  care  be  not  taken  to  make  a  direct  examination.  How 
often  is  the  uterus  regarded  as  the  source  of  the  pain,  when  the  lesion  is  precisely 
located  in  the  pelvic  articulations! 

The  spontaneous  pains  produced  by  relaxation  of  the  pelvic  symphyses  are  more 
particularly  awakened  by  motion  of  the  lower  extremities,  as  in  walking  and  stand- 
ing, and  usually  subside  upon  lying  down.  In  slight  cases  walking  is  difficult,  the 
patients  are  soon  fatigued,  drag  their  limbs,  and  are  unable  to  stand  upon  one 
foot.  In  a  more  advanced  stage,  walking  becomes  increasingly  difficult,  painful,  and 
finally,  impossible.  When  the  patient  would  stand,  the  sensation  is  as  though  the 
sacrum  descended  between  the  iliac  bones,  or  as  though  the  body  would  drop  be- 
tween the  thighs.  It  is  then  quite  possible  by  moving  the  lower  extremities  to 
perceive  the  motion  of  the  ilia,  and  sometimes  even  a  very  sensible  crackling  or 
clicking  can  be  detected.  In  one  of  M.  Trousseau's  patients  the  end  of  the  fore- 
finger could  be  readily  inserted  between  the  two  pubic  bones  and  a  softened  con- 
dition of  the  interarticular  cartilage  perfectly  detected. 

Relaxation  of  the  pelvic  symphyses  is  often  greater  after  delivery  than  during 
gestation,  and  though  more  evident  during  the  lying-in,  is  still  often  overlooked, 
and  the  pains  which  it  occasions  attributed  to  metritis  or  uterine  displacement.  In 
all  these  cases,  however,  the  symptoms  are  the  same  and  require  similar  treatment. 
^  The  prognosis  is  variable  ;  in  slight  cases  no  treatment  is  required  and  the  affec- 
tion disappears  after  delivery.  In  a  more  advanced  stage,  rest  in  bed  is  insuffi- 
cient, and  an  appropriate  treatment  becomes  necessary.  Sometimes  three,  six,  or 
eight  months,  or  several  years,  are  required  for  the  consolidation  to  take  place.  In 
one  of  M.  Martin's  patients  the  cure  was  postponed  until  after  another  labor. 
There  are  facts,  indeed,  which  go  to  prove  that  relaxation  of  the  symphyses  may 
continue  through  life  in  spite  of  the  best  treatment.  Finally,  in  the  following 
article  we  shall  speak  of  Inflammation  and  suppuration  of  the  symphyses,  which  may 
also  occur  and  lend  fresh  gravity  to  the  affection. 


516  PATHOLOGY  OF  PREGNANCY. 

As  soon  as  the  relaxation  is  discovered,  the  patient  should  le  put  to  bed  aid  kepi 
strictly  at  rest,  with  the  pelvis  held  motionless  by  means  of  a  compressory  bandage. 
For  this  purpose  a  towel  passed  around  the  pelvis  and  drawn  very  tight,  may 
answer  in  the  simplest  eases.  The  procedure  is  at  once  a  rational  treatment  and  a 
means  of  diagnosis,  inasmuch  as  relief  is  generally  immediate,  and  if  successful, 
leaves  no  doubt  as  to  the  nature  of  the  disease.  Bandages  of  linen  or  ticking  are, 
however,  liable  to  stretch  and  loosen  in  a  very  short  time,  in  which  case  a  good 
substitute  is  found,  according  to  Boycr,  in  a  leather  belt  quilted  internally  and 
caused  to  surround  the  pelvis  between  the  great  trochanter  and  crest  of  the  ilium 
and  buckled  in  front.  The  best  apparatus,  however,  is  the  one  recommended  and 
used  by  M.  Martin.  It  is  composed  of  a  strong  circular  piece  of  metal  two  inches 
wide,  open  in  front,  and  large  enough  to  embrace  the  entire  circumference  of  the 
pelvis.  It  is  padded  and  quilted  like  the  spring  of  a  truss  and  provided  at  one 
end  with  a  strung  strap  and  with  a  buckle  at  the  other,  whereby  the  ends  are 
brought  together  and  held  firmly.  This  apparatus  has  the  advantage  of  being 
applicable  during  pregnancy  without  interfering  with  the  development  of  the 
abdomen,  and  is  even  more  useful  after  delivery.  Although  its  weight  is  consider- 
able, the  patients  soon  become  accustomed  to  its  use.  It  secures  immobility  of  the 
bones  so  fully  that  absolute  quietness  is  no  longer  necessary,  and  the  patients  may 
walk  every  day  without  the  recovery  being  interfered  with. 

"We  owe,"  says  M.  Danyau,  "the  acknowledgment  to  M.  Martin,  that  his  belt 
fulfils  all  the  indications,  and  that  none  other  does  so  more  effectually.  Not  only  is 
it,  like  layer's,  narrow  enough  to  clasp  the  pelvis  where  the  pressure  can  produce 
neither  interference  nor  injury  and  be  at  the  same  time  really  effective,  that  is  to 
say,  between  the  crests  of  the  ilia  and  the  great  trochanters,  but  what  is  not  less 
important,  it  is  so  strong  and  stiff  that  when  once  applied  and  the  bones  brought  in 
contact  by  it,  separation  afterward  becomes  impossible."] 

When  to  relaxation  of  the  pelvic  articulations,  inflammatory  symptoms 
are  added,  they  should  be  met  by  the  appropriate  means;  in  their  absence, 
we  may  apply  gentle  pressure  around  the  pelvis,  and  make  use  of  some 
topical  applications,  general  and  local  tonics.,  and  astringent  and  resolvent 
lotions.  After  the  total  disappearance  of  the  lochia,  Desormeaux  highly 
extols  the  employment  of  douches,  sea-bathing,  a  good  diet  of  nutritive 
articles,  the  Spa  and  Seltzer  waters,  wearing  flannel  next  to  the  skin,  and 
dry  frictions.  We  cannot  recommend  too  highly  the  use,  in  these  cases,  of 
the  steel  girdle  of  M.  Martin,  which,  when  tightly  drawn  around  the  pelvis, 
immediately  restores  a  portion  of  its  normal  solidity,  and  facilitates  the  cure 
wonderfully. 

These  measures  should  be  continued  for  a  long  time,  and  even  when  con- 
valescence is  fully  established,  the  greatest  possible  care  must  be  exercised 
in  rising,  walking,  &c. 

§  2.  Inflammation  of  the  Pelvic  Articulations. 

Inflammation  of  the  pelvic  articulations,  which  is  sometimes  observed 
after  labor,  may  also  occur,  though  more  rarely,  during  pregnancy.  Drs. 
Hiller,  Monod,  Danyau,  and  Professor  Hayn,  of  Konigsberg,  have  men- 
tioned instances  of  it. 

The  disease  generally  begins  without  appreciable  cause  with  sudden, 
acute,  sometimes  lancinating,  though  usually  heavy  pain,  in  one  or  several 
of  the  pelvic  articulations.  The  pain  is  increased  by  pressure, standing, and 
i  specially  by  attempts  at  walking,  which  i-s  sometimes  altogether  impossible. 


DISEASES     OF     PREGNANCY.  517 

These  pains  often  extend  into  the  lower  extremities,  and  especially  into 
the  thighs.  Swelling  can  sometimes  be  detected  over  the  inflamed  articula- 
tions 

These  articular  pains  are  sometimes  attended  by  a  febrile  movement, 
which  is  o.  casionally  severe,  though  generally  quite  moderate.  In  some 
cases,  indeed,  there  is  almost  no  general  reaction. 

The  inflammation,  when  moderate,  usually  yields  promptly  to  proper 
treatment ;  the  cure  is  almost  perfect  after  twelve  or  fifteen  days,  and  the 
delivery  and  lying-in  seem  to  experience  no  unfavorable  effect  from  it.  In 
some  cases,  however,  whether  in  consequence  of  the  intensity  of  the  inflam- 
mation, or  because  the  proper  means  were  not  employed  with  sufficient- 
energy,  the  disease  ended  in  suppuration,  and  in  two  instances  proved  fatal. 
In  these  cases,  the  articular  surfaces  were  found  denuded  of  cartilage.  MM. 
Hiller  and  Monod  mention  two  cases  which  proved  fatal  in  this  manner. 

If  the  pains  are  very  acute,  and  the  general  reaction  decided,  general 
and  local  bleeding  may  be  employed  at  the  outset.  But  when  there  is  no 
fever,  and  the  local  symptoms  are  moderate,  we  may  be  content,  with  resol- 
vent applications,  restricted  diet,  and  absolute  repose  in  the  horizontal  pos- 
ture. Narcotics  may  be  added  to  the  resolvent  applications,  if  the  pains 
are  too  severe. 

ARTICLE  VIII. 

DISEASES   OF   THE   VULVA   AND    VAGINA. 

[Various  lesions  of  the  vulva  and  vagina  impede  delivery,  and  are  therefore  dis- 
cussed in  the  article  on  Dystocia.  At  present  we  shall  describe  only  pruritus  of 
the  vulva,  leucorrhcea,  and  vegetations,  as  they  occur  in  pregnant  women. 

\  1.  Pruritus  op  the  Vulva. 

Pruritus  of  the  vulva,  though  not  peculiar  to,  often  occurs  during  pregnancy.  It 
is  characterized  by  intense  itching  of  the  external  genital  parts,  the  labia  majora 
and  minora,  and  often  extends  even  into  the  vagina.  The  itching  is  irresistible, 
obliging  the  patients  to  scratch  themselves,  and  thus,  in  consequence  of  tne  relief 
afforded,  leads  to  a  sort  of  masturbation. 

Examination  of  the  affected  parts  discovers  no  appreciable  alteration  :  sometimes 
there  is  redness,  at  others  some  exudation  of  serum  with  superficial  liberations 
reminding  one  of  eczema.     (Hardy.)] 

The  itching  was  so  insupportable  in  a  young  married  lady  under  Aiy  care, 
that  she  could  not  refrain  from  continual  scratching,  and  the  gen^ai  irrita- 
tion resulting  therefrom  almost  threw  her  into  convulsions. 

In  another  instance,  a  young  girl,  who  wished  to  conceal  her  preguancy, 
was  so  tormented  by  this  disease,  that  it  was  absolutely  impossible  to  hide 
her  distress  from  the  observation  of  her  family;  and  when  I  examined  her, 
I  found  the  internal  face  of  the  labia  externa,  and  the  nymphse,  both  swollen 
and  inflamed  from  the  constant  scratching;  the  nympha  on  the  right  side 
had  been  so  long,  and  so  strongly  dragged  upon,  that  it  had  acquired  twice 
the  usual  length  at  least.  Generally  speaking,  the  frequent  use  of  bathing, 
and  of  the  vegeto-mineral  lotions  applied  live  or  six  times  a  day, will  calm 
the  itching;  and  as  it  is  often  greatly  aggravated  by  walking,  perfecl  rest  is 


518  PATHOLOGY  OF  PREGNANCY. 

of  course  indicated.  Some  advantage  is  often  to  be  derived  from  a  fine 
compress  dipped  in  oil  of  sweet  almonds,  and  then  placed  in  the  vulvar 
fissure;  or  still  better,  if  the  compress  be  soaked  in  lead-water. 

Dewecs  states  that  he  examined  a  young  lady  who  complained  of  this 
excessive  itching  in  the  genital  parts,  and  he  found  the  internal  face  of  the 
vulva,  as  also  the  inferior  part  of  the  vagina,  covered  by  numerous  aphthae; 
and  that  the  application  of  a  strong  solution  of  borax,  four  or  five  times  a 
dav,  caused  them  all  to  disappear  in  the  course  of  twenty-four  hours. 

Dr.  Meigs  has  always  found  the  following  preparation  useful:  — 

R— Borax 3'j- 

Sulph.  of  morphia,      .......         gr.  ivss. 

Dist.  rose  water, foyiii. 

Apply  three  times  a  day  to  the  affected  parts,  by  means  of  a  sponge  or 
piece  of  linen,  taking  care  to  wash  the  parts  beforehand  with  soap  and  water, 
and  to  dry  them  well  afterwards.  The  following  solution  of  bichloride  of 
mercury  may  also  be  used  with  advantage :  Add  a  drachm  and  a  half  of 
corrosive  sublimate  to  four  ounces  of  distilled  water,  and  of  this  solution  let 
the  patient  add  a  dessert-spoonful  to  a  pint  of  very  warm  water,  and  use  for 
injections  and  lotions.  Hot  water  alone  will  answer  in  many  cases.  (Trous- 
seau and  Pidoux.) 

[Pruritus  of  the  vulva  is  often  very  obstinate.  In  the  rebellious  cases  mentioned, 
M.  Dubois  adviscs'that  the  entire  mucous  surface  of  the  vulva  be  cauterized  with 
the  solid  nitrate  of  silver.  A  great  objection  to  it  however  is,  that  it  is  extremely 
painful  anil  almost  always  produces  but  temporary  alleviation.  We  have  generally 
succeeded  with  a  solution  of  corrosive  sublimate,  as  follows: 

R.  —  Bichloride  of  mercury, gr.  xxxi. 

Alcohol, f3iij- 

Rose  water, f^iss. 

Distilled  water, f5xv> 

This  is  used  as  a  wash,  undiluted,  morning  and  even'ng,  as  follows:  After  using 
warm  water  for  the  purpose  of  removing  mucous  secretions  from  the  vulva,  and 
(Irving  the  parta  well  with  a  piece  of  fine  linen,  a  small  sponge  saturated  with  tho 
Uuid  is  passml  rapidly  over  the  entire  itching  surface,  so  as  to  moisten  it  thoroughly. 
A  smart  burning  sensation  is  the  first  effect  of  the  application,  which  is  alleviated 
by  a  few  minutes  washing  with  cold  water.  Subsequent  applications  are  less  and 
less  painful,  and  the  cure  is  generally  rapid.     AVe  prefer  this  treatment  to  all  others  J 

§  2.  Leucorrhcea. 

"We  shall  limit  ourselves  to  a  short  notice  of  the  profuse  leucorrhoea  with 
which  women  are  very  often  affected  during  pregnancy.  This  discharge, 
which  is  sometimes  white  and  sometimes  of  a  yellowish-green  color,  usually 
makes  its  appearance  during  the  second  half  of  gestation,  though  I  have 
Been  some  persons  affected  with  it  from  the  early  months.  It  is  generally 
coincident  with  the  development  of  numerous  granulations,  which,  as  we 
have  already  said,  sometimes  cover  the  vaginal  mucous  membrane,  and 
constitute  what  has  been  described  of  late  as  granular  vaginitis.  When  it 
is  very  profuse,  an  examination  by  the  speculum  frequently  discovers 
numerous  ulcerations  of  the  ueck  of  the  uterus.     We  shall  have  occasion 


DISEASES    OF    PREGNANCY.  51^ 

to  speak  of  these  ulcerations  hereafter.  I  am  convinced  that  the  vaginal 
granulations  and  ulcerations  of  the  cervix  are  very  rarely  as  serious  during 
gestation  as  they  appear  to  be  under  some  other  circumstances  since  they 
generally  disappear  with  the  pregnancy,  during  which  they  are  developed. 

Sometimes  the  discharge  is  so  abundant  as  to  react  upon  the  functions  of 
the  stomach,  and  I  have  seen  several  patients  with  symptoms  of  gastralgia, 
evidently  connected  with  the  leucorrhcea,  inasmuch  as  they  increased  or 
diminished  according  as  the  latter  was  more  or  less  profuse.  _ 

This  affection  often  produces,  in  addition,  great  irritation,  a  burning  heat, 
and  sometimes  an  almost  insupportable  itching  of  the  lower  part  of  tha 
vagina  and  external  genitals.  A  profusion  of  small  vesicles  appear  upon 
the  internal  surface  of  the  greater  and  lesser  labia,  which,  by  constantly 
rubbing  against  each  other,  finally  give  rise  to  excoriation,  and  render 
walking  very  painful. 

Frequent  baths,  lotions,  and  injections  of  cold  water,  to  each  quart  of 
which  a  dessertspoonful  of  subacetate  of  lead  has  been  added,  repeated 
several  times  daily,  according  to  the  degree  of  pain,  are  the  best  remedies. 
It  will  also  be  found  advantageous  to  separate  the  parts,  by  introducing  a 
piece  of  fine  linen  between  the  labia,  so  as  to  prevent  friction  whilst  walking. 
It  is  unnecessary  to  say  that  the  introduction  of  the  speculum  during  preg- 
nancy requires  that  especial  care  be  taken  not  to  press  it  too  far. 

Though  the  patient's  sufferings  may  easily  be  alleviated  in  this  manner, 
it  is  more  than  probable  that  the  granulations  will  continue,  and  that  the 
discharge  will  not  cease  entirely ;  in  spite  of  all  that  can  be  done,  it  gener- 
ally lasts  until  the  end  of  pregnancy,  and  in  the  great  majority  of  cases 
only  terminates  after  delivery. 

Would  any  disadvantage  attend  the  insertion  in  the  vagina  of  tampons  formed 
of  carded  cotton  and  alum?  Would  they  be  likely  to  occasion  abortion  or  pre- 
mature delivery  ?  During  my  present  temporary  service  at  the  Lourcme  hospital, 
I  have  found  quite  a  number  of  pregnant  women  affected  with  vaginitis  and  profuse 
ieucorrhoea,  and  in  all  such  cases  it  is  the  practice  there  to  use  the  above-named 
tampons,  notwithstanding  the  fact  of  pregnancy.  I  continue  them  as  they  have 
been  used  heretofore,  though  not  without  apprehension;  still  no  accident  hat 
occurred  as  yet.  I  should  desire,  however,  a  longer  experience,  before  I  could  feel 
willing  to  advise  them.  .  „   . 

Vaginal  injections,  especially  if  used  indiscreetly,  may  excite  contraction  of  the 
uterus  and  abortion,  if  the  fluid  be  thrown  upon  the  os  tincaa. 

\  3.  Vegetations. 

The  external  parts  of  generation,  particularly  in  women  affected  with  blennorrhea, 
vaginitis,  or  uterine  catarrh,  often  become  covered  with  vegetations,  which  were 
long  supposed  to  be  of  a  syphilitic  character.  They  seem  always  to  be  connected 
with  the  presence  of  a  discharge  in  non-pregnant  females;  that  their  production 
may  also  be  favored  by  pregnancy,  is  a  fact  established,  as  I  think,  by  the  treatise 

of  M.  Thibierge.  .    ,     .         .     .  „ 

The  vegetations   may  appear   in   pregnant  women   at  any  period  of  gestation. 

They  consist  of  tufts  of  a  rosy  hue,  attached  by  a  pedicle,  and  spreading  out  like 

a  cauliflower.     In  respect  to  number  and  size  they  vary  greatly. 

They  may  he  either  scattered  or  so  grouped  as  to  form  large  masses.     A  patient 

in  the  Hosnital  of  the  Clinic  had  them  in  the  form  of  a  tumor  as  large  us  the  list- 


520  PATHOLOGY  OF  PREGNANCY. 

Thev  affect  more  especially  the  mucous  membrane  of  the  vulva,  though  they  also 
form  on  the  external  surface  of  the  labia  major  a,  in  the  furrow  between  the  but- 
tocks, about  the  region  of  the  anus  and  the  genito-crural  folds:  sometimes,  even, 
they  sprout  from  the  walls  of  the  vagina  or  the  os  tincae,  though  in  these  situations 
they  are  generally  small. 

They  are  attended  with  itching,  considerable  pain,  and  a  discharge.  They  also 
exhale  a  very  unpleasant  odor,  but  are  really  devoid  of  danger,  and  occasion  no 
obstruction  to  delivery,  even  when  of  large  size.  In  the  majority  of  cases  the} 
disappear  spontaneously  after  delivery;  the  pedicle  dries  up,  and  they  fall  like  a 
ripe  fruit.     This  favorable  termination  is  not,  however,  universal. 

One  of  their  peculiarities  is  that  of  continuing  to  sprout  during  gestation  in  spite 
of  all  kinds  of  treatment.  Still.  M.  Thibierge  thinks  that  the  use  of  local  appli- 
cations during  pregnancy  may  dissipate  them  when  small  and  few  in  number. 
Under  other  circumstances  they  are  almost  certain  to  return. 

In  regard  to  treatment  during  pregnancy,  an  attempt  may,  in  the  first  place,  be 
made  to  destroy  them  by  local  applications,  as  of  alum,  nitric  acid,  or  the  acid 
nitrate  of  mercury  applied  drop  by  drop.  Excision,  and  even  crushing,  are  liable 
to  occasion  obstinate  hemorrhage,  so  that  radical  operations  ought  not  to  be  per- 
formed. After  delivery,  should  the  trouble  persist,  any  of  the  methods  of  treat- 
ment used  in  such  cases  become  applicable.] 

ARTICLE    IX. 

ABDOMINAL   AND   UTERINE   PAINS. 

Beside  the  numerous  functional  disorders  just  studied,  some  pregnant 
women  suffer,  in  various  parts  of  the  body,  pains  whose  intimate  cause  is 
imperfectly  understood,  and  to  which  they  sometimes  call  the  attention  of 
the  physician.  Some  of  these  pains  appear  to  be  seated  in  the  abdominal 
parietes,  the  lumbar  region,  the  groins,  and  the  internal  part  of  the  thighs ; 
others,  again,  appear  to  affect  more  especially  the  walls  of  the  uterus,  or 
the  annexes  of  that  organ. 

§  1.  Abdominal,  lumbar,  and  Inguinal  Pains. 

T hcse  pains,  which  are  sometimes  confined  to  a  quite  limited  space  of  the 
abdominal  parietes,  do  not  often  appear  before  the  latter  months  of  gesta- 
tion. They  are  frequently  felt  at  the  lower  part  of  the  breast,  near  the 
upper  insertions  of  the  abdominal  muscles,  or,  less  often,  in  the  inguinal 
folds  near  their  inferior  attachments.  The  pains  are  much  increased  by 
motion,  the  least  pressure,  and  sometimes,  also,  by  the  movements  of  the 
child,  if  violent.  As  already  stated,  they  are  generally  limited  in  extent, 
sometimes  not  affecting  a  space  larger  than  a  silver  dollar,  the  parts  sur- 
rounding being  entirely  free  from  pain. 

Since  lumbar  and  inguinal  pains,  occurring  in  the  first  half  of  gestation, 
may  be  the  preludes  of  an  abortion  near  at  hand,  they  claim  special  atten- 
tion. At  this  early  period  they  are  almost  uniformly  the  sympathetic  ex- 
pression of  uterine  disorder, itself  due  to  a  local  congestion, though  perhaps 
.-till  oftener  to  a  special  irritability  of  the  womb.  They  then  resemble  pre- 
cisely the  lumbar  and  inguinal  pains  which  are  so  often  experienced  by 
young  girls  affected  with  dysmenorrhea  or  amenorrhoea,  and  are  effectually 
overcome  by  opiates,  small  revulsive  bleedings,  and  sometimes, also,  in  very 


DISEASES   OF    PREGNANCY.  521 

nervous  women,  by  warm  bathing.  If,  as  is  often  the  case,  the  pains  seem 
to  be  increased  by  sexual  intercourse,  too  long  a  walk,  or  riding  in  a  carriage, 
it  were  useless  to  say  that  abstinence  from  all  these  causes,  and  repose  in  the 
horizontal  posture,  are  the  first  indications  to  be  fulfilled. 

These  pains  most  commonly  appear  toward  the  end  of  pregnancy,  but 
their  cause,  that  especially  of  the  lumbar  pains,  is  very  obscure.  Some- 
times, however,  it  can  be  ascertained  that  they  are  seated  in  the  pelvic 
articulations  (see  page  515).  Dragging  upon  the  broad  ligaments,  com- 
pression of  the  lumbar  nerves,  extreme  distention  of  the  uterus,  and 
engorgement  of  the  pelvic  and  uterine  vessels,  have  been  successively  ad- 
duced in  explanation  ;  but  though  the  relief  obtained  from  bleeding,  in 
some  cases,  would  seem  to  show  that  they  might  sometimes  be  caused  by 
local  plethora,  there  is  no  evidence  of  any  such  influence  as  is  attributed 
to  the  other  causes  mentioned. 

The  inguinal  pains  have  generally  been  referred  to  traction  upon  the 
round  ligaments.  I  do  not  say  that  this  traction  may  not  produce  them, 
but  I  am  convinced  that  toward  the  end  of  pregnancy  they  are  oftener 
due  to  the  pressure  of  the  uterus  upon  that  region,  in  the  vertical  as  well 
as  in  the  sitting  posture.  They  generally  disappear,  indeed,  in  the  hori- 
zontal position,  and  the  best  means  of  relieving  the  patients  is  to  support 
the  abdomen,  and  at  the  same  time  raise  it  a  little  by  means  of  a  well-made 
corset,  or  of  a  large  abdominal  belt,  the  central  portion  of  which  embraces 
the  sub-umbilical  region,  and  whose  two  ends  are  attached  to  the  back  part, 
of  the  corset. 

[Having  for  some  time  made  a  special  study  of  these  abdominal,  inguinal,  and 
lumbar  pains,  we  are  convinced  that  very  often  they  are  due  to  neuralgia  of  the 
cutaneous  nerves  from  the  collateral  branches  of  the  lumbar  plexus.  To  be  assured 
that  such  is  the  case,  it  is  only  necessary  to  test  carefully  the  sensibility  of  the 
skin  in  these  regions,  either  by  rubbing  it  rudely  with  the  end  of  a  pencil,  or  by 
raising  it  in  the  form  of  a  fold  which  is  to  be  gradually  pinched  between  the 
fingers.  Pressure  ought  also  to  be  made  all  along  the  crest  of  the  ilium  in  the 
direction  of  the  genito-crural  nerve.  Should  we  be  satisfied  with  merely  question- 
ing the  patients,  or  depressing  the  walls  of  the  abdomen  by  the  hand,  we  would 
incur  the  risk  of  obtaining  very  little  information,  or  of  suspecting  the  existence 
of  a  deep-seated  visceral  pain  when  the  skin  only  is  affected.  This  mistake,  which 
we  see  committed  every  day,  would  be  avoided  by  taking  the  trouble  to  make  the 
above-mentioned  examination,  and  we  cannot  recommend  it  too  highly. 

The  principal  parts  affected  by  this  neuralgia  are  the  lumbar,  iliac,  hypogastric, 
and  inguinal  points,  though  the  pain  may  appear  in  some  other  portion  of  greater 
or  less  extent  of  the  skin  of  the  abdomen.  Sometimes  confined  to  a  circumscribed 
point,  it  occasionally  invades  an  entire  half  of  the  abdominal  walls.  It  very 
rarely  affects  both  sides  at  the  same  time  with  equal  intensity. 

The  local  application  of  narcotics  constitutes  the  treatment  par  excellence,  of 
these  neuralgic  pains.  We  have  almost  always  succeeded  with  very  small  blisters 
sprinkled  with  one  of  the  salts  of  morphia.  Subcutaneous  injections  are  also 
clearly  indicated,  and  none  of  these  methods  are  liable  to  effect  unfavorably  the 
couise  of  the  pregnancy. 

What  we  have  just  written  applies  especially  to  the  abdominal  neuralgia  of 
pregnanl  women;  but  before  leaving  the  subject,  we  desire  to  say  thai  the  same 
affection   is  also  extremely   common   after  delivery.      In   t  J  i  *  -   latter  case,   however, 


522  PATHOLOGY  OF  PREGNANCY. 

instead  of  being  ihe  chief  pathological  element,  it  is  almost  always  symptomatic 
of  a  lesion  of  some  one  of  the  pelvic  organs.  Its  investigation  is  not,  on  this 
account,  less  important,  because,  generally,  the  intensity  of  an  inflammation  is 
estimated  by  the  acuteness  of  the  pain  which  it  produces.  Under  these  circum 
stances,  if  the  skin  be  raised  carefully  between  two  fingers,  and  the  fold  thus 
formed  be  pinched,  it  is  often  found  that  the  pain  is  seated  partly  in  the  skin  and 
not  in  the  uterus  or  its  appendages.  The  physician  is  thus  better  informed,  since  a 
slight  metro-ovaritis  may  be  attended  by  a  violent  cutaneous  neu  llgia  more 
alarming  by  far  than  dangerous. 

The  lumbo-abdominal  neuralgia  which  is  symptomatic  of  a  metro-ovaritis  or  of 
a  metro-peritonitis,  also  enables  us  to  understand  certain  facts  which  would  be 
inexplicable  without  it.  Suppose  a  newly  delivered  female  to  be  attacked  by 
metritis;  the  uterus  is  examined  by  depressing  the  walls  of  the  abdomen  by  the 
hand,  and  several  examinations  carefully  conducted  assure  us  that  pain  is  produced 
about  the  fundus  of  the  organ.  The  usual  treatment  in  such  a  case  consists  in 
the  application  of  leeches  directly  over  the  seat  of  pain,  and,  we  must  say,  almost 
alwavs  affords  relief.  Is  it  not  surprising  that  such  a  result  should  be  produced? 
How  could  we  suppose  that  an  abstraction  of  blood  from  the  skin  of  the  abdomen 
near  the  umbilicus  would  act  directly  upon  the  fundus  of  the  uterus  when  all 
vascular  communication  between  the  two  parts  is  prevented  by  the  interposition 
of  the  peritoneum  ?  We  bow  before  the  facts,  yet  believe  that  the  bites  of  the 
leeches,  when  they  afford  relief,  do  so  by  acting  directly  upon  the  cutaneous 
neuralgia  which  is  symptomatic  of  the  metritis,  and  have  no  effect  upon  the 
vascular  engorgement  of  the  uterus.  The  same  result  would  follow  the  applica 
tion  of  a  blister  dressed  with  a  salt  of  morphia.  As  soon  as  time  shall  permit, 
we  intend  publishing  several  cases  which  go  to  prove  what  we  have  just  said 
respecting  the  part  played  by  lumbo-abdominal  neuralgia  during  pregnancy  and 
in  the  diseases  of  lying-in  women.] 

The  pains  in  the  internal  parts  of  the  thighs,  the  numbness  and  cramps 
of  both  legs,  though  more  commonly  of  one  only,  are  usually  attributed  to 
pressure  of  the  head  on  the  lumbar  and  sacral  nerves.  But,  as  Tyler  Smith 
remarks,  since  they  mostly  occur  at  night,  when  the  women  are  in  the  hori- 
zontal posture,  or  whilst  they  are  sitting,  in  both  which  positions  the  pressure 
should  be  much  less  than  whilst  standing,  it  seems  very  probable  that  com- 
pression of  the  nerves  is  not  the  cause.  Perhaps  we  may  accept  the  idea  of 
the  English  accoucheur,  that,  like  the  corresponding  affections  in  cholera, 
they  are  connected  with  some  irritation  or  difficulty  of  the  large  intestine,  or 
with  a  morbid  condition  of  the  uterus.  It  would  not  be  the  only  instance 
of  visceral  irritation  producing  spasmodic  contraction  of  the  muscles  of 
animal  life  by  reflex  action. 

According  to  this  hypothesis,  the  best  means  of  preventing  the  recurrence 
of  the  cramp  is  to  keep  the  bowels  free,  and  allay  the  irritability  of  the  womb 
a3  much  as  possible  by  baths,  opiates,  &c.  The  surest  means  of  cc  interact- 
ing it  is  to  contract  voluntarily,  the  very  moment  it  appears,  the  antagonistic 
muscle  of  the  affected  one  ;  thus  the  thigh  should  be  strongly  extended  when 
the  flexor  muscles  are  contracted,  and  the  foot  should  be  flexed  on  the  leg 
when  the  cramp  affects  the  muscles  of  the  calf. 

§  2.  Uterine  Pains. 

1.  Beside  the  uterine  pains  which  sometimes  accompany  the  outset  of  a 
disordered  pregnancy,  also  beside  those  which  seem  to  herald  the  approach 


DISEASES     OF     PREGNANCY.  523 

of  labor  in  the  latter  weeks  of  gestation,  females  experience,  at  variable 
periods  and  intervals,  pains  which  are  sometimes  very  acute,  anl  evidently 
seated  in  the  walls  of  the  uterus  itself.  It  is  impossible  to  determine  the 
cause  and  nature  of  these  pains  ;  for  though  they  may  be  attributed,  in  some 
rare  instances,  to  partial  spasm  of  the  muscles  of  the  uterus,  or  to  a  more 
or  less  extensive  inflammation,  most  frequently  nothing  of  the  kind  is  to  be 
discovered.  Sometimes  they  are  limited  to  a  single  circumscribed  point, 
whilst  at  others  they  affect  the  entire  womb.  In  the  first  case  they  are  con- 
tinuous ;  in  the  second,  they  are  irregularly  intermittent,  and  their  recur- 
rence,  or  rather  their  paroxysm,  appears  to  coincide  with  a  motion  of  the 
female,  pressure  upon  the  abdomen,  an  attack  of  coughing,  or  sudden  move- 
ments of  the  child.  At  the  same  time  the  uterine  tumor  may  almost  always 
be  felt  to  become  denser  and  harder:  in  short,  a  true  contraction  takes 
place,  which  continues  as  long  as  the  paroxysm  lasts.  If,  struck  with  this 
condition  of  the  body  of  the  womb,  an  examination  be  made  pervaginam, 
the  cervix  will  be  found  unchanged,  having  undergone  no  alteration  which 
could  excite  solicitude  on  account  of  the  long-continued  previous  contrac- 
tions.    Usually,  there  is  very  slight  general  reaction,  and  little  or  no  fever. 

When  the  pain  is  both  circumscribed  and  moderate,  emollient  and  nar- 
cotic applications  may  be  found  sufficient ;  but  when  more  severe,  it  will  be 
necessary  to  prescribe  the  most  absolute  repose,  injections  with  camphor  and 
laudanum,  baths,  maniluvia,  and  even  bleeding  from  the  arm.  It  generally 
yields  to  these  measures  when  properly  employed,  though,  unfortunately,  it 
returns  with  some  individuals  very  frequently.  I  have,  at  this  moment,  a 
young  lady  under  care,  who  is  at  the  eighth  month  of  her  pregnancy,  and 
who  has  had  five  attacks  within  three  months,  two  of  them  lasting  for 
twenty-four  hours.  The  first  time  she  was  bled ;  but  as  her  general  condi- 
tion seemed  to  contraindicate  a  repetition  of  this  measure,  and  she  was 
very  averse  to  bathing,  I  was  obliged  to  content  myself  with  prescribing 
rest  and  opiate  injections.     Now,  there  is  every  prospect  of  her  reaching  her 

full  term. 

2.  The  sensibility  of  the  uterus  is  sometimes  singularly  increased  by  con- 
stant and  violent  motions  of  the  foetus.  Some  children,  indeed,  seem  en- 
dowed with  such  activity  that  they  are  hardly  ever  quiet,  and  their  con- 
tinual movement  becomes  a  cause  of  irritation  to  the  womb,  which,  by  re- 
acting upon  the  whole  economy,  may  produce  insomnia,  general  excitement, 
and  nervous  and  sometimes  even  convulsive  movements.  I  have  seen  two 
instances  of  these  disordered  motions  of  the  child;  especially  was  it  marked 
in  the  case  of  the  wife  of  one  of  my  professional  brethren.  This  poor 
lady  was  delivered  at  term,  notwithstanding  she  had  been  almost  entirely 
deprived  of  sleep  during  the  eighth  and  ninth  months.  Burns  says,  that 
patients  under  these  circumstances  are  delivered  rather  before  the  ninth 
month.  The  bleeding  and  opiates  which  he  recommends  may  indeed  lessen 
the  irritability  of  the  uterus,  but  evidently  can  have  no  power  to  diminish 
the  activity  of  the  motions  of  the  child,  which  is  the  first  cause  of  the 
uterine  pains.1 

»  Dr.  Tyler  Smith  endeavors  to  show,  in  a  very  interesting  memoir,  thai  the  active 
motions  of  the  child  amount  to  almost  nothing,  and  that  the  sensations  perceived  by 


524  PATHOLOGY   OF    PREGNANCY. 

3.  Some  authors  state  that  metritis,  or  metro-peritonitis,  are  possible 
during  pregnancy,  but  they  are  so  rare  that  it  has  never  fallen  to  my  lot  to 
see  them.  Besides,  they  seem  to  me  to  belong  to  the  same  category  as  all 
the  acute  affections  which  may  arise  during  pregnancy ;  and  though  the 
usual  gravity  of  the  prognosis  be  heightened  by  the  condition  of  the  female, 
the  treatment  would  be  the  same  as  after  delivery. 

§  3.  Rheumatism  of  the  Uterus. 

Rheumatism  of  the  uterus,  although  studied  for  a  long  time  in  Germany, 
was  scarcely  known  in  France,  until  M.  Dezeimeris  published  in  his  journal 
(J Experience)  a  series  of  facts  that  were  previously  known  to,  and  put  forth 
by,  the  German  authors.  About  the  same  time,  M.  Stoltz,  who  was  ac- 
quainted with  the  works  of  our  neighbors  &n  the  subject,  devoted  particular 
attention  to  this  affection  at  the  Clinical  Hospital  of  Strasbourg,  and  com- 
municated the  result  of  his  observations  to  his  pupils.  One  of  them,  Dr. 
Salathe,  has  quite  recently  defended  a  thesis  on  this  subject ;  and  from  his 
work,  as  also  from  the  bibliographical  researches  of  M.  Dezeimeris,  I  extract 
the  following  account  of  this  disease,  which  is  unknown  to  French  nosologists. 

According  to  Radamel,  rheumatism  may  attack  the  uterus  in  the  non- 
gravid  state ;  but  we  have  only  to  study  it  here  as  occurring  in  pregnant 
females,  in  whom  it  may  appear  at  all  stages  of  the  puerperal  condition. 
Therefore,  after  some  general  remarks  on  the  disease  itself,  it  will  be  neces- 
sary to  point  out  the  influence  that  it  may  have  over  the  gestation,  the  par- 
turition, and  the  lying-in. 

Causes. — Every  circumstance  calculated  to  favor  the  development  of  the 
rheumatic  affections  in  general,  may  likewise  prove  a  source  of  rheumatism 
of  the  uterus:  thus,  a  momentary  or  a  prolonged  exposure  to  cold  and 
moisture,  inadequate  clothing,  or  sudden  changes  from  a  very  high  to  a  very 
low  temperature,  and  all  those  other  atmospheric  constitutions  which  have 
been  enumerated  by  medical  authors,  either  as  predisposing  or  as  determin- 
ing causes  of  rheumatism,  may  likewise  produce  that  of  the  womb.  But, 
besides  these  general  causes,  there  is  one  peculiar  to  the  disease  under  con- 
sideration ;  that  is,  the  susceptibility  of  this  organ  to  the  impression  of  cold 
under  the  attenuated  integuments  of  the  abdomen  during  the  latter  months 
of  gestation  ;  for  the  belly  is  only  covered  at  that  particular  point  by  very 
light  clothing,  which  is  far  from  fitting  closely,  and  the  lumbo-sacral  region 
is  often  but  imperfectly  protected  by  the  short  jackets  worn  by  the  patient. 

Symptoms.  —  Rheumatism  of  the  uterus  very  often  occurs  in  persons  who 
are  constitutionally  predisposed  to  the  rheumatic  affections ;  and  it  may  co- 
exist with  a  general  disorder  of  the  same  nature,  though  in  the  majority  of 
cases  the  womb,  together  with  its  appendages  and  the  adjacent  parts,  is 
alone  affected.     Again,  it  has  oftentimes  resulted  from  a  sudden  cessation 

the  mother  and  accoucheur,  hitherto  attributed  to  the  muscular  contractions  of  the 
child,  result  simply  from  partial  contraction  of  the  muscular  fibres  of  the  uterus.  Not- 
withstanding the  seductive  character  of  the  reasons  adduced  by  Dr.  Smith,  we  hold  tc 
the  generally  received  opinions,  though  entirely  disposed  to  think  that  the  views  of 
the  English  accoucheur  may  be  applicable  to  the  exceptional  cases  of  which  we  are 
speaking. 


DISEASES     OF     PREGNANCY.  525 

of  a  rheumatic  pain  at  some  other  point,  which  is  speedily  transferred  to  the 
uterus.  But,  whatever  may  Have  been  the  mode  of*  its  attack,  this  disease 
exhibits  some  well-marked  peculiarities,  by  which  it  can  easily  be  recognized. 
The  principal  symptom  is  pain,  or  a  distressing  sensation,  which  involves 
the  whole,  or  a  part  of  the  womb,  without  any  violence  having  been  exerted 
on  the  organ  ;  its  intensity  varies  from  a  simple  feeling  of  heaviness  to  the 
most  painful  dragging  sensation  ;  and  it  may  occupy  either  the  entire  womb, 
or  only  one  of  its  parts,  such  as  the  body,  the  fundus,  or  the  inferior  segment. 
When  the  rheumatism  is  fixed  in  the  fundus  uteri,  the  pain  is  particularly 
apt  to  be  felt  in  the  sub-umbilical  region  ;  it  is  augmented  by  pressure,  by 
the  contraction  of  the  abdominal  muscles,  and  sometimes  even  by  the  simple 
weight  of  the  bedclothes ;  and  in  many  cases  the  patient  is  unable  to  bear 
auy  movement  whatever.  If  seated  somewhat  lower,  she  suffers  from  acute 
dragging  sensations,  that  run  from  the  loins  toward  the  pelvis,  the  thighs, 
the°external  genital  organs,  and  the  sacral  region,  along  the  uterine  liga- 
ments. Finally,  when  the  inferior  segment  participates  in  the  affection,  the 
seat  of  it  can  be  detected  by  the  vaginal  exploration,  which  gives  rise  to  the 
most  acute  sufferings.  But,  of  all  the  causes  that  may  exasperate  these 
pains,  there  are  none  more  distressing  than  the  incessant  movements  of  the 

child.' 

Like  all  rheumatic  pains,  those  of  the  uterus  are  metastatic,  and  they 
occasionally  pass  rapidly  from  one  point  of  the  organ  to  another ;  often, 
indeed,  they  disappear  at  once,  and  pass  off  to  some  other  organ.  This  is 
particularly  apt  to  occur  when  the  pain  was  originally  located  at  some  other 
point,  and  measures  have  been  employed  to  recall  the  affection  to  the  part 
primitively  attacked. 

They  present  frequent  and  variable  exacerbations  in  their  duration  and 
intensity,  according  to  the  stage  of  the  disease ;  sometimes  they  are  followed 
by  remissions,  during  which  the  patient  experiences  only  a  vague  sensation 
of  weight  in  the  part.  The  uterine  pains  are  usually  accompanied  by  a 
recto- vesical  tenesmus,  which  is  the  more  distressing  as  the  former  are  the 
more  energetic,  and  are  seated  near  the  inferior  segment.  The  patient  is 
then  tormented  by  a  continual  desire  to  empty  her  bladder ;  the  emission  of 
urine  is  attended  by  a  smarting  sensation,  and  sometimes  by  acute  sufferings, 
while  at  others  it  is  even  wholly  impossible;  and  in  many  cases  the  attempts 
to  move  the  bowels  prove  equally  ineffectual.  Most  of  the  German  authors 
attribute  this  double  recto-vesical  tenesmus  to  a  rheumatic  affection  that  is 
not  always  exclusively  limited  to  the  womb,  but  which  also  invades  the 
neighboring  organs.  But  M.  Stoltz  appears  disposed  to  believe  that  it  is 
rather  the  result  of  the  close  sympathy  existing  between  these  adjacent  parts  ; 
for,  if  these  new  pains  were  occasioned  by  a  rheumatism  of  the  rectum  or 
bladder,  those  of  the  uterus  ought  to  disappear  altogether,  or  at  least  should 
be  diminished.     (Salatke's  Thesis.) 

Analogy  would  lead  us  to  suppose  that  an  unusual  heat  and  tumefaction 
must  exist  in  the  affected  parts ;  but  the  difficulties  in  detecting  these  char- 
acters are  self-evident,  although  their  existence  is  quite  probable. 

Such  acute  pains,  seated  in  so  important  an  organ,  would  naturally  pro- 
duct' considerable  general  reaction;  and  it  is  found  that  this  disease,  like 


02G  PATHOLOGY   OF   PREGNANCY. 

the  greater  number  of  the  inflammatory  affections,  most  usually  commences 
by  a  slight  chill,  which  lasts  for  a  quarter  of  an  hour  or  twenty  minutes; 
the  fever  that  follows  it  diminishes,  and  sometimes  disappears  altogether, 
during  the  interval  between  the  paroxysms;  but,  pending  their  duration,  it 
is  usually  quite  intense,  the  pulse  is  frequent  and  hard,  the  face  excited  and 
flushed,  and  the  tongue  is  red  and  dry  ;  the  patient  complains  of  thirst,  the 
<kiii  is  hot,  and  she  often  suffers  from  an  extreme  agitation  and  restlessness. 
Towards  the  end  of  the  paroxysm,  a  profuse  perspiration  generally  breaka 
cut,  which  seems  to  be  the  prelude  of  a  notable  amelioration.  Then  these 
general  phenomena  become  moderated,  together  with  the  uterine  pain,  but 
they  reappear  with  the  latter,  after  a  variable  period,  ranging  from  a  few 
hours  to  several  days. 

1.  Influence  of  Rheumatism  over  the  Progress  of  Gestation. — The  parox- 
ysms are  apt  to  be  followed  by  uterine  contractions  in  those  cases  in  which 
they  have  persisted  for  some  time,  or  have  been  very  severe ;  and  in  this 
manner  they  may  serve  to  bring  on  a  premature  delivery.  The  patient 
experiences  some  acute  and  tensive  pains,  but  this  feeling  of  tension  is  not 
uniform  ;  for  it  attains,  in  turn,  a  high  degree,  and  then  becomes  weaker  in 
the  same  proportion,  progressing  in  this  way  with  shorter  and  shorter  inter- 
vals. At  first  the  uterus  is  indurated  to  a  partial  extent,  but  afterwards 
throughout;  the  os  uteri  dilates,  though  its  dilatation  is  at  first  slow  and 
difficult,  and  its  ulterior  progress  does  not  seem  to  correspond  with  the 
intensity  of  the  pains.  An  abortion  is  then  imminent,  but  it  is  far  from 
being  so  frequent  as  might  be  supposed;  and  when  it  does  occur,  it  is  more 
frequently  observed  in  the  febrile  than  in  the  apyretic  form  of  rheumatism. 
The  orifice  has  been  known  to  dilate  to  the  extent  of  an  inch  in  diameter, 
and  then  the  bag  of  waters,  that  had  previously  engaged  in  this  opening, 
insensibly  retreated,  the  os  uteri  again  closed  up,  and  the  delivery  did  not 
take  place.  Consequently,  so  long  as  the  dilatation  of  the  os  uteri  does  not 
amount  to  two  inches,  we  may  reasonably  hope  to  make  the  labor  retrograde. 
These  uterine  rheumatic  paius  may  simulate  those  of  parturition,  and  thus 
lead  the  accoucheur  to  suspect  that  labor  has  regularly  commenced,  when 
in  fact  such  is  not  the  case.  The  characters  of  the  rheumatic  pain,  furnished 
in  the  following  paragraph,  will  aid  in  preventing  such  an  error.  It  is 
probably  to  some  mistakes  of  this  kind  that  we  must  refer  those  pretended 
instances  of  prolonged  gestation,  as  well  as  those  cases  in  which  genuine 
labor  was  developed,  and  afterwards  suspended  during  several  weeks,  and 
even  months. 

'1.  Influence  of  Rheumatism  over  the  Labor.  —  As  a  general  rule,  a  rheu- 
matic affection  of  the  womb  retards  the  progress  of  the  labor,  and  sometimes 
even  renders  the  spontaneous  expulsion  of  the  child  wholly  impossible. 
Besides  the  general  phenomena  already  pointed  out,  the  disease  here  gives 
rise  to  the  following  peculiarities : 

1st.  It  is  well  known  that  the  normal  uterine  contraction  only  begins  to 
be  painful  when  it  has  accomplished  the  greater  part  of  its  course,  and  when 
it  is  at  the  point  of  distending  and  dilating  the  uterine  orifice ;  in  other 
words,  the  true  labor-pain  only  commences  at  the  instant  when  the  power 
of  the  body  of  the  womb  overcomes  the  resistance  of  the  neck.    In  rheuma- 


DISEASES     OF     PREGNAXCY.  527 

tism,  on  the  con  trary,  the  uterine  contraction  is  painful  from  the  very  first, 
and  prior  to  any  action  upon  the  cervix  ;  hence  ihe  cause  of*  the  pain  is  not 
in  the  violent  distention  of  this  orifice,  but  rather  in  the  uterine  contraction 
itself,  in  the  other  morbid  conditions,  and  in  the  altered  relations  of  the 
nerves  and  contractile  fibres  of  the  uterus. 

-d.  In  a  normal  labor,  the  contractions  begin  at  the  fundus,  and  termi- 
unte  at  the  inferior  segment  of  the  womb  ;  in  rheumatism,  instead  of  starting 
at  the  fundus,  they  begin  in  the  painful  point,  and  are  not  regularly  propa- 
gated towards  the  cervix.  Again,  the  rheumatic  pains  exist  prior  to  the 
contraction  of  the  womb,  and  then  speedily  acquire  a  high  degree  of  inten- 
sity under  the  influence  of  this  latter.  At  times  their  violence  promptly 
arrests  the  contractions,  even  before  they  have  traversed  their  ordinary  cycle. 
They  are  then  rapid,  short,  and  become  more  and  more  distant. 

3d.  Towards  the  end  of  labor,  at  the  time  when  the  uterine  action  ought 
to  be  aided  by  the  voluntary  contraction  of  the  abdominal  muscles,  the 
woman  refrains  from  exerting  these  under  the  fear  of  augmenting  the  pains., 
whereby  an  excessive  slowness  in  the  labor  results.  The  patient  is  found  in 
a  state  of  extreme  anxiety,  and  the  frequency  of  her  pulse,  the  heat  of  the 
skin,  the  thirst,  and  vesical  tenesmus,  are  all  greatly  augmented.  Where 
these  sufferings  are  much  prolonged,  she  falls  into  a  state  of  swooning,  which 
often  proves  serviceable,  as  the  pains  are  suspended  while  it  lasts ;  a  pro- 
fuse perspiration  has  then  been  observed  to  take  place,  which  had  the  most 
salutary  influence  over  the  ulterior  progress  of  the  parturition.  But  at 
other  times  the  uterus  becomes  more  and  more  painful,  and  it  is  rather  in 
a  state  of  permanent  contraction,  or  of  fibrillar  vibration,  than  of  normal 
contraction ;  the  pulse  is  accelerated,  and  the  woman  is  affected  with  a  me- 
tritis which  renders  the  labor  extremely  painful. 

?.  Influence  of  Rheumatism  over  the  Puerperal  Functions. — The  reader 
will  anticipate  from  the  foregoing,  that  rheumatism  of  the  womb  may  prove 
a  source  of  difficulty  in  the  delivery  of  the  after-birth,  by  determining 
irregular  or  partial  contractions  of  the  organ  immediately  after  the  expul- 
sion of  the  child ;  but  that  subject  does  not  claim  our  attention  at  the 
present  time,  and  it  will  be  reverted  to  hereafter.  In  the  healthy  state,  the 
uterus  retracts  after  the  delivery,  and  thereby  prevents  the  development  of 
hemorrhage.  But  in  rheumatism,  this  retraction  of  the  organ  is  very  im- 
perfect, and  it  remains  much  larger  than  usual ;  the  after-pains  are  then 
very  distressing,  and  are  prolonged  for  some  time ;  the  uterine  vessels  are 
less  compressed  than  usual,  and  profuse  floodings  may  thence  result.  On 
the  other  hand,  the  suffering  state  of  the  organ  diminishes  both  the  lochia! 
discharge  and  the  lacteal  secretion  ;  and  this,  together  with  the  persistence 
of  the  abdominal  pains,  and  a  manifestation  of  the  phenomena  of  general 
reaction,  may  be  mistaken  for  a  peritonitis  which  does  not  really  exist. 

Prognosis.  —  Rheumatism  of  the  womb  is  not  a  disease  capable  of  deter- 
mining the  loss  of  the  mother's  life;  nevertheless,  from  the  pain  that  it 
occasions,  and  the  errors  it  may  give  rise  to  in  practice,  it  does  not  the  less 
merit  a  careful  study;  because,  during  pregnancy,  it  may  prove  to  be  a 
source  of  abortion,  and  though  it  is  not  often  manifested  until  after  the  sixth 
month,  yet  it  is  always  an  unfavorable  circumstance  to  the  child  to  be  bom 


528  PATHOLOGY  OF  PREGNANCY. 

before  term.  We  have  already  spoken  of  the  unfortunate  influence  it  may 
have  over  the  course  and  character  of  the  labor-pains ;  in  fact,  it  has  often 
rendered  an  artificial  delivery  imperative.  It  may  also  complicate  the  de- 
livery of  the  after-birth,  and  disturb  the  order  of  the  phenomena  that  con- 
stitute the  lying-in.  At  that  period  it  has  often  been  mistaken  for  true 
inflammatory  symptoms,  and,  consequently,  has  been  combated  by  measures 
that  were  more  dangerous  than  useful. 

As  regards  the  period  of  manifestation,  it  is  generally  more  unfavorable 
when  it  occurs  at  an  early  stage  of  the  gestation  ;  both  because  it  then  has 
a  greater  influence  over  the  pregnancy,  which  has  not  become  firmly  estab- 
lished, and  because  it  has  a  tendency  to  return  several  times  before  term. 
Besides  which,  most  women,  who  have  been  affected  during  the  gravid  state, 
likewise  find  it  to  reappear  again  in  the  course  of  parturition,  which  is 
thereby  rendered  laborious. 

Treatment.  —  1st.  The  measures  that  have  most  frequently  been  attended 
with  success  when  administered  for  this  disease  during  the  gestation  are: 
general  venesection  ;  the  intestinal  revulsives,  such  as  castor-oil  and  ipecacu- 
anha ;  bathing,  narcotized  lotions  over  the  abdomen,  opiated  mixtures,  and 
sudorific  drinks ;  and  in  those  cases  in  which  the  uterine  affection  had  suc- 
ceeded the  sudden  disappearance  of  a  rheumatic  pain  in  some  other  organ, 
the  application  of  revulsives  over  the  part  primarily  affected.  2d.  During 
the  labor,  the  same  means  are  employed  ;  but  if  they  fail,  and  the  degree  of 
dilatation  of  the  os  uteri  be  such  as  to  permit  an  artificial  intervention,  either 
the  forceps  or  version  should  be  resorted  to,  according  to  circumstances. 
3d.  After  the  delivery,  sudorific  drinks,  opiated  unctions  over  the  belly,  and 
baths ;  and  when  the  lochial  discharge  has  failed,  leeches  to  the  vulva,  and 
ipecacuanha  combined  with  opium. 

ARTICLE    X. 

of  displacements  of  the  uterus  considered  in  reference  to  the 
accidents  they  may  cause  during  pregnancy. 

§  1.  Prolapsus  of  the  Uterus. 

We  have  already  seen,  in  studying  the  situation  of  the  uterus  at  the  dif- 
ferent periods  of  gestation,  that  at  first  this  organ  sinks  lower  in  the  exca- 
vation, and  that  its  orifice  approaches  the  vulva.  Now  this  first  degree  of 
depression  may  be  considered  as  physiological,  but  it  cannot  pass  beyond 
that  without  giving  rise  to  some  accident  or  other.  Hence,  laying  aside  all 
causes  foreign  to  pregnancy,  the  uterus  descends  the  more  in  the  earlier 
months  of  gestation  in  proportion  to  the  larger  size  of  the  pelvis,  and  the 
greater  relaxation  of  the  ligaments.  In  some  women  it  rests  on  the  floor 
of  the  pelvis,  whilst  in  others,  the  neck,  or  even  the  body,  may  protrude 
through  the  vulva  and  become  visible  externally. 

We  see,  therefore,  that  either  a  simple  descent  or  an  incomplete  or  com- 
plete prolapsus  may  occur  during  pregnancy,  as  well  as  in  the  non-pregnant 
condition.  The  complete  prolapsus,  that  in  which  the  entire  body  of  the 
iterus  is  external  to  the  genital  parts  and  hangs  between  the  thighs,  is  ex- 
tremely rare.  It  were  wrong,  however,  to  deny  its  possibility,  since  this  is 
proved  by  a  case  reported  by  Vimmer. 


DISEASES     OF     PREGNANCY.  529 

Tnese  displacements  may  occur  either  slowly  or  suddenly,  th  nigh  the 
lemale  may  have  had  nothing  of  the  kind  previously;  sometimes,  however, 
they  are  but  the  continuation  or  exaggeration  of  a  pre-existing  prolapsus. 
Although  the  progressive  development  of  the  uterus  generally  removes  the 
incomplete  prolapsus  about  the  fourth  or  fifth  month,  by  causing  the  organ 
to  rise  above  the  superior  strait,  the  displacement,  in  some  cases  where  the 
pelvis  is  spacious,  may  continue,  and  even  increase,  notwithstanding  the 
progress  of  gestation.  I  have,  quite  recently,  had  under  care  at  ;he  Clin- 
ique,  a  very  remarkable  case  of  incomplete  prolapsus,  in  which  the  entire 
neck  of  the  uterus  projected  beyond  the  external  parts,  the  whole  excava- 
tion being  occupied  by  the  lower  part  of  the  body  distended  by  the  foetal 
head.  The  displacement  continued  until  delivery  without  any  serious  acci- 
dent supervening.1    It  had  existed  for  several  years. 

1  The  following  are  some  of  the  details  of  this  interesting  case:   Marie  ,  aged 

twenty-seven  years,  entered  the  hospital  October  18th,  1849.  She  was  then  at  the 
beginning  of  the  ninth  month  of  her  pregnancy.  Four  years  previously,  she  became 
pregnant  for  the  first  time,  and  when  near  delivery,  she  both  felt  and  saw  a  small  red 
tumor,  of  about  the  size  of  a  walnut,  escape  through  the  vulva.  It  projected  but 
slightly,  incommoded  the  patient  but  little,  and  did  not  interfere  with  the  labor  at  all, 
since  the  latter  was  accomplished  quite  rapidly.  After  her  confinement,  she  continued 
to  feel  the  same  tumor,  less  prominent,  indeed,  than  during  pregnancy,  projecting  and 
disappearing  according  as  she  was  quiet  or  took  long,  fatiguing  walks.  Under  the 
latter  circumstances  she  suffered  much  from  sensations  of  dragging  in  the  groins  and 
upper  part  of  the  thighs.  She  was  habitually  and  obstinately  constipated,  and  some 
times  had  great  difficulty  in  urinating. 

Two  years  ago,  the  same  person  became  pregnant  the  second  time,  and  during  the 
first  three  months  the  tumor  became  gradually  more  projecting,  and  hung  very  low, — 
so  low,  she  says,  that  a  midwife,  after  having  returned  the  parts,  applied  a  pessary, 
which  produced  discomfort,  and  was  retained  but  two  days.  Eight  days  after  the 
introduction  of  the  pessary,  she  miscarried,  at  about  three  months  and  a  half  to  four 
months.  The  midwife  who  attended  her  could  not  extract  the  placenta,  and,  two  days 
afterwards,  a  physician  endeavored  to  deliver  it,  first  with  the  hand,  and  afterwards 
with  forceps,  but  could  obtain  only  some  fragments. 

She  recovered  entirely;  the  tumor  remaining  within  whilst  quiet  in  her  chamber, 
but  appearing  externally  after  much  walking. 

Becoming  pregnant  for  the  third  time,  the  tumor  did  not  incommode  her  much  more 
than  usual  during  the  first  three  months,  but  after  the  fourth,  it  projected  much  more 
from  the  vulva,  and  towards  the  last  three  months  it  was  impossible  to  restore  it  for 
several  days,  even  after  observing  the  most  absolute  repose  in  bed.  At  present,  the 
patient,  being  eight  months  and  a  half  gone,  the  following  may  be  observed: 

A  cylindrical  tumor,  two  inches  in  length,  projects  from  the  vulva;  it  is  five  inches 
in  circumference,  and  rather  larger  and  harder  at  its  lower  than  at  its  upper  extrem- 
ity. Its  external  surface  is  marked  at  the  union  of  the  two  upper  thirds  with  the  lower 
one  by  a  whitish  circle,  dividing  two  surfaces  of  different  color  and  appearance.  The 
superior  is  of  a  rosy  hue  and  smooth,  being  only  the  internal  surface  of  the  vagina 
inverted  from  above  downwards,  which  thus  forms  the  external  surface  of  the  tumor. 
The  inferior  portion  is  of  a  deeper  red  color,  and  presents  wrinkles  or  folds,  directed 
from  above  downwards,  and  from  within  outwards,  and  separated  on  the  median  line 
by  apparently  longitudinal  fibres.  These  folds  are  merely  the  arbor  vitas  of  t lie  neck 
inverted  from  below  upwards,  so  that  the  internal  surface  of  the  cavity  of  (he  neck 
has  become  a  part  of  the  external  surface  of  the  tumor  to  the  extent  of  five-eighths 
of  an  inch.  The  somewhat  swollen  lower  extremity  of  this  turn  or  presents  an  opening, 
with  wrinkled  edges,  resembling  the  drawn  mouth  of  a  purse,  and  into  which  the 
34 


530  PATHOLOGY   OF    PREGNANCY. 

In  some  cases  the  displacement  increases  considerably,  and  either  as  an 
cflect  of  its  own  weight,  or  in  consequence  of  exertion  or  violent  exercise,  the 
lower  part  of  the  body  of  t lie  uterus  projects  beyond  the  vulva,  the  upper 
part  of  the  organ  being  still  within  the  pelvis. 

finger  enters  with  ease.  This  is  the  cavity  of  the  neck,  forming  a  canal  two  inches 
and  three-quarters  in  length,  through  which  the  membranes  and  a  hard  body,  recog- 
nized as  the  head  of  the  foetus,  may  be  felt.  The  internal  orifice  is  quite  largely  di- 
lated, that  is,  nearly  to  the  size  of  a  one-franc  piece.  The  entire  head  is  discovered 
to  be  in  the  excavation,  and  altogether  behind  the  symphysis  pubis,  by  which  it  seems 
to  be  arrested. 

If  it  be  attempted  to  enter  the  vagina,  at  the  same  time  traversing  the  circumference 
of  the  upper  part  of  the  tumor,  a  cul-de-sac  is  reached  at  a  depth  of  from  two  inches 
and  three-quarters  to  three  inches  and  a  quarter  on  the  sides,  from  two  and  a  half 
inches  to  three  inches  and  a  quarter  behind,  and  from  only  two  to  two  and  a  half  in 
front,  when  the  examination  is  stopped  by  the  walls  of  the  urethra,  which  are  thickened 
and  curved,  as  it  were,  posteriorly. 

This  cul-de-sac  is  formed  by  the  vagina  turned  inside  out  from  above  downwards; 
and  any  effort  to  push  it  upwards  is  soon  arrested  by  the  foetal  head,  which  is  plunged 
into  the  excavation,  and  rests  upon  the  floor  of  the  pelvis. 

The  patient  suffers  from  obstinate  constipation,  and  sometimes  only  from  difficulty  in 
passing  urine,  which  escapes  by  jets. 

To  recapitulate,  we  find:  1.  A  descent  of  the  womb,  which  seems  to  be  retained  in 
t lie  pelvis  only  by  the  floor  of  the  latter,  and  the  pubic  arch  and  symphysis,  against 
which  it  rests;  the  rectum  and  urethra  are  also  compressed.  2.  Prolapsus  of  the  neck 
of  the  uteius  outside  of  the  vulva,  carrying  with  it  the  vagina,  which  covers  its  upper 
part  like  the  inverted  finger  of  a  glove,  and  which  is  itself  inverted  from  below  upward 
to  the  extent  of  five-eighths  of  an  inch,  so  that  its  internal  surface  forms  the  external 
surface  of  its  lower  extremity;  this  extremity  of  the  neck  forms  the  expanded  aDd 
wrinkled  portion  of  the  tumor.  8.  Constipation  and  difficulty  in  urination  caused  by 
pressure. 

The  tumor  increased  about  three-quarters  of  an  inch  in  size,  from  the  20th  of  Octo- 
ber to  the  3d  of  November;  but  its  volume  was  much  greater  in  consequence  of  the 
(edematous  condition  of  the  prolapsed  parts. 

After  some  fruitless  efforts  to  reduce  the  prolapsus,  I  concluded  that  it  would  be 
best  not  to  try  any  further,  but  to  limit  treatment  to  evacuation  of  the  bowels  by  mild 
laxatives,  —  the  patient  being  unable  to  receive  encmata,  —  a  bath  every  two  or  three 
days,  atid  frequent  lotions  and  injections.  Assisted  by  the  horizontal  posture,  these 
measures  completely  relieved  the  patient  of  her  sufferings. 

.\t  noon  on  the  3d  of  November,  the  waters  came  away  without  pain,  after  efforts  at 
defecation.  The  internal  orifice  of  the  cervix  was  of  the  size  of  a  one-franc  piece;  the 
neck  was  rather  longer  than  before  the  3d,  and  rather  softer.  During  the  last  ten 
days  the  patient  felt  her  abdomen  become  harder  from  time  to  time,  but  without  ex- 
periencing the  least  pain. 

From  noon  until  10  p.  m.  the  pains  were  very  weak  and  distant.  From  10  o'clock 
to  3  a.m.  (of  the  4th),  they  became  greater,  more  powerful  and  frequent.  Finally, 
the  labor  terminated  at  3  a  m.  the  4th  of  November,  after  a  labor  of  fifteen  hours,  if 
the  time  be  reckoned  from  the  rupture  of  the  membranes  and  discharge  of  the  waters, 
and  only  of  five  hours,  if  counted  from  10  p.  m.,  at  which  time  there  was  no  change  in 
either  the  length  or  dilatation  of  the  neck,  though  then  it  was  that  the  pains  became 
well  marked  and  regular. 

The  following  are  the  principal  phenomena  which  accompanied  the  expulsion  of  th<; 
foetus:  At  the  commencement  of  labor,  the  neck  remained  external  precisely  as  before, 
and  when  the  head  came  to  be  expelled,  it  dilated  visibly,  and  was  the  last  obstacle 
which  this  pari  had  to  overcome.  No  resistance  was  offered  by  the  vulva,  which  was 
traversed  before  the  external  orifice  of  the  neck  of  the  uterus. 


DISEASES    OF    PREGNANCY.  531 

The  disorders  resulting  from  this  displacement  vary  in  intensity  according 
to  its  extent  and  the  stage  of  pregnancy  at  which  it  occurs.  When  the  pelvis 
is  too  spacious,  the  excess  of  size  affecting  chiefly  the  excavation,  whilst  the 
straits  preserve  their  normal  dimensions,  the  uterus  may  remain  much  longer 
in  the  lesser  pelvis  than  is  usual  in  well-formed  women.  It  then  incommodes 
the  neighboring  parts,  pressing  upon  and  irritating  the  rectum  and  the  blad- 
der; the  patient  suffers  from  a  feeling  of  weight  at  the  anus,  and  painful 
tractions  in  the  groins,  lumbar  regions,  and  umbilicus.  A  more  or  les3 
abundant  and  fetid  discharge  also  comes  on ;  the  woman  can  neither  stand 
nor  walk  without  suffering,  and  she  falls  gradually  into  a  state  of  marasmus. 

When  the  gestation  is  more  advanced,  and  the  womb  increased  in  size,  or 
even  if  less  voluminous,  but  more  depressed,  the  symptoms,  such  as  com- 
plete retention  of  the  urine,  very  obstinate  constipation,  &c,  are  still  worse ; 
finally,  the  pressure  of  the  uterus  on  other  organs  may  react  on  itself,  and 
the  consequent  irritation  thus  prove  a  cause  of  abortion. 

When  the  retention  of  the  urine  is  complete,  either  the  catheter  should  be 
at  once  resorted  to,  or  the  womb  be  pressed  up  by  one  or  two  fingers  pre- 
viously introduced  into  the  vagina;  but  even  this  assistance  will  not  be 
necessary,  if  the  woman  lies  down  and  elevates  her  hips  considerably  when- 
ever she  wants  to  urinate.  All  these  symptoms,  however,  disappear  about 
the  fifth  month,  when  the  uterus,  on  account  of  its  great  development,  can 
no  longer  remain  in  the  excavation,  and  therefore  rises  above  the  superior 
strait. 

In  cases  of  simple  and  incomplete  prolapsus,  some  authors  recommend  the 
introduction  of  a  pessary,  in  order  to  sustain  the  uterus,  and  prevent  its 
prolapsing  completely.  I  regard  the  pessary  as  always  useless  and  often 
dangerous.  Rest  in  bed,  and  proper  cleanliness,  seem  to  me  capable  of  pre- 
venting the  precipitation  of  the  organ,  and  of  alleviating  the  painful  irrita- 
tions which  the  displacement  produces. 

Certain  instances  of  success  seem  to  authorize  attempts  at  reduction  in 
cases  of  incomplete  and  complete  prolapsus  occurring  at  an  advanced  stage 
of  pregnancy.  In  both  circumstances,  I  think  that  these  attempts  should 
be  moderate,  since  they  appear  to  me  likely  to  compromise  the  gestation. 
When  the  prolapsus  is  complete,  the  danger  to  which  the  woman  is  exposed 

The  child,  which  was  a  male,  was  born  alive.     Its  weight  and  dimensions  were  as 
fc  lows : 

Weight,        ...... 

Total  length,     ...... 

From  the  crown  to  the  umbilicus, 

From  the  umbilicus  to  the  heel, 

Occipto-frontal  diameter, 

Occipito-mental  "  .... 

Bi-parietal  "  .  .  .  .  3|  " 

Sub-occipito-bregmatic  diameter,        ...  8J  " 

The  day  following  the  labor,  the  cervix  projected  to  the  same  extent  outBide  the 
vulva,  and  the  parts  were  rather  more  flaccid  :  the  engorgement  being  dissipated,  the 
neck  was  returned  within  the  vagina  ;  the  patient  continued  in  the  horizontal  position, 
and  a  month  after  left  the  Clinique  without  ihe  neck  having  appeared  ai  the  vulvar 
opening. 


1  ft 

ll.s. 

.6 
'J 
9 

(Troy), 
inches. 

II 
II 

4 

II 

5 

<< 

532  PATHOLOGY  OF  PREGNANCY. 

by  the  nature  of  the  displacement  itself  would  certainly  authorize  .-ather 
greater  perseverance;  but  it  is  easy  to  see  that  in  the  latter  months  it  will 
rarelv  be  possible  to  return  the  uterus  within  the  pelvis. 

When  the  reduction  is  impossible,  the  uterine  tumor  should  be  supported 
by  a  proper  bandage,  and  the  female  confined  to  the  horizontal  position. 

In  women  who  have  had  a  falling  of  the  womb  before  impregnation,  thtre 
is  reason  to  fear  that  it  may  persist  and  augment  during  the  first  three  01 
four  months  of  gestation,  in  consequence  of  the  great  laxity  of  the  ligaments ; 
and  it  is  therefore  prudent  to  advise  such  persons  to  keep  the  horizontal 
position  during  all  this  time,  and  not  to  permit  them  to  get  up  until  after 
the  fifth  month.  After  the  delivery,  they  should  again  remain  in  bed  six 
weeks  or  two  months  at  least;  for  by  such  precautions,  not  only  may  the 
patient  escape  the  clangers  attendant  on  a  prolapsus  uteri  during  the  earlier 
periods,  but  sometimes  even  a  radical  cure  of  the  disease  she  had  before  the 
gestation  took  place  may  be  effected. 

§  2.  Retroversion. 

The  mobility  of  the  uterus  in  the  pelvis,  which  is  still  observable  in  the 
early  stages  of  pregnancy,  notwithstanding  its  augmentation  in  volume, 
exposes  it  to  another  variety  of  displacement,  that  is  not  so  common  as  the 
preceding,  but  more  disastrous  in  its  consequences.  Thus,  in  some  instances, 
the  womb  seems  to  execute  a  see-saw  movement,  by  which  its  long  vertical 
a\is  is  brought  into  a  nearly  horizontal  line  in  the  excavation,  in  such  a  way 
ihat  the  fundus  remains  either  a  little  more  elevated,  or  else  somewhat  more 
depressed  than  the  neck.  This  displacement  is  called  retroversion,  when  the 
fundus  uteri  is  carried  backwards  into  the  hollow  of  the  sacrum,  and  ante- 
version,  when  it  is  directed  towards  the  symphysis  pubis.  These  two  varieties 
may  occur  in  different  degrees ;  but  the  displacement  will  be  much  more 
considerable  in  retroversion  than  in  anteversion,  on  account  of  the  anterior 
concavity  of  the  sacrum  ;  the  former  is  also  more  frequent  and  serious  than 
the  latter. 

Finally,  in  the  latter  part  of  gestation,  the  uterus  may  incline  more  or 
'ess  to  the  right  or  the  left,  so  as  to  constitute  what  have  been  termed  lateral 
obliquities. 

[If  we  may  credit  M.  Salmon  (of  Chartres),  -who  has  published  an  excellent 
thesis  for  the  "Concours"  on  the  subject,  retroversion  of  the  uterus  during  preg- 
nancy is  not  a  very  uncommon  occurrence.  Having  already  met  three  cases  in  our 
own  practice,  we  are  the  more  ready  to  accept  his  opinion  as  probably  correct.  It 
usually  happens  between  the  third  and  fourth  months,  and  is  rare  before  the  third  and 
after  the  fifth  months.  The  observed  cases  occurred  much  more  frequently  in  those 
who  had  already  borne  children,  than  in  those  who  were  pregnant  for  the  first  time. 

As  the  displacement  may  be  gradual  or  sudden,  we  may  describe  it  according  to 
its  character  in  these  respects. 

The  causes  of  gradual  retroveision  are:  the  normal  inclination  of  the  fundus 
of  the  womb  toward  the  hollow  of  the  sacrum  in  early  pregnancy;  the  more  rapid 
development  of  its  posterior  surface  at  the  same  period;  a  spacious  pelvis,  as  in- 
sisted nn  by  M.  <  liaillv  ;  the  constant  pressure  upon  the  fundus  by  the  abdominal 
viscera;  ami  above  all,  a  collection  of  faeces  in  the  sigmoid  flexure,  of  the  colon,  and 
retention  of  urine.     Numerous  discussions   have   taken   place   in   regard   to  the  eflect 


DISEASES    OF    PREGNANCY.  533 

of  retention  of  urine  in  the  production  of  this  displacement,  some  thinking  that 
the  retention  is  an  effect  and  not  the  cause,  whilst  others  believe  that  distention  of 
the  bladder,  so  far  from  producing,  would  actually  prevent  the  occurrence  of  retro- 
version. We  agree  with  those  who  regard  retention  of  urine  as  the  principal  cause 
of  the  gradual  displacement,  basing  our  opinion  upon  the  fact  that,  by  frequent 
emptying  of  the  bladder  by  the  catheter,  the  displacement  will  be  spontaneously 
removed.  As  other  causes  of  this  occurrence  during  pregnancy,  we  have  noted 
a  previous  retroversion,1  the  growth  of  abdominal  tumors  and  adhesions  resulting 
i'rum  an  old  peritonitis,  &c] 

When  the  retroversion  occurs  suddenly,  it  is  produced  by  the  same  mech- 
anism, only  a  more  vigorous  and  energetic  impulsion  is  then  requisite  ;  and 
such  an  impulsion  is  usually  given  by  a  rapid,  violent  contraction  of  the 
muscles :  thus,  after  a  severe  retching,  or  vomiting,  or  after  the  strainings 
at  stool,  in  women  who  are  habitually  constipated,  or  in  urinating,  in  cases 
of  retention,  the  womb  is  often  found  displaced. 

M.  Moreau  relates  an  instance  of  a  woman  who  lifted  a  weight  of  fifty 
pounds,  for  the  purpose  of  placing  it  on  the  balance,  when  she  was  imme- 
diately attacked  by  pains  in  the  hypogastrium,  vomiting,  syncope,  &c.  On 
his  arrival,  he  found  the  uterus  completely  turned  backwards ;  but  all  these 
symptoms  disappeared  immediately  after  the  reduction  was  effected.  A  fall 
backwards,  or  blows,  or  a  strong  pressure  below  the  navel,  have  very  fre- 
quently caused  the  same  result.  (Nsegele.)  In  one  of  Hunter's  cases,  the 
retroversion  appeared  soon  after  a  severe  fright. 

"  A  woman,"  says  M.  Martin,  of  Lyons,  "  was  taken  in  her  third  month, 
after  a  violent  straining  effort,  with  pains,  accompanied  by  loss  of  blood  ; 
at  first,  the  os  tincse  was  found  in  the  centre  of  the  vagina;  but  the  patient 
renewed  her  efforts,  and  then  the  uterus  became  completely  retroverted,  that 
is,  the  neck  was  placed  behind  the  pubis  and  a  little  to  the  right,  and  the 
fundus  of  the  organ  rested  against  the  sacrum.  In  this  instance  the  retro- 
version evidently  resulted  from  the  conjoint  influence  of  the  uterine  con- 
tractions and  the  expulsory  efforts  of  the  abdominal  muscles."  (Martin, 
Memo  ires,  p.  142.) 

Where  the  displacement  is  effected  slowly,  the  woman  is  but  little  incom- 
moded at  first;  and  the  necessity  for  reduction  is  only  apparent  after  it  has 
become  considerable.  Originally,  there  are  only  some  painful  dragging 
sensations  in  the  groins  and  lumbar  region ;  a  feeling  of  weight  and 
pressure  on  the  neck  of  the  bladder;  some  vesical  tenesmus,  and  a  little 
difficulty  in  the  emission  of  urine.  But  when  the  uterus  attains  a  certain 
degree  of  development,  all  these  phenomena  increase,  and  we  are  then 
obliged  to  interpose  the  resources  of  our  art;  for  when  matters  reach  this 
s',ate,  the  womb  becomes  wedged,  as  it  were,  in  the  middle  of  the  pelvis,  and 
even  more  firmly  so  afterwards,  because  its  volume  augments  rapidly;  lor 
not  only  does  the  foetus  continue  its  growth,  but  also  the  uterine  walls 
become  engorged,  tumefied,  and  inflamed,  and  the  symptoms  caused  ny  this 
inflammation  are  added  to  those  previously  existing;  and,  further,  as  the 
space  then  occupied  and  filled  up  by  the  uterus  is  larger  than  the  superior 
strait,  the  reduction  becomes  very  difficult,  or  even  impossible.  Hunter 
relates  a  case  in  which  the  reduction  could  not  he  made,  and  the  woman 

1  According  to  Tyler  Smith,,  retroversion,  in  the  great  majority  of  cases  observed  in 
pregnancy,  has  its  origin  in  a  previously  rotroverted  or  retrotlexeil  uterus. 


534  PATHOLOGY  OF  PREGNANCY. 

died  in  consequence;  and  at  the  autopsical  examination  it  was  fo.md  i^eces- 
sary  to  cut  through  the  symphysis,  in  order  to  disengage  the  womb  from  thfl 
excavation. 

When  the  displacement  takes  place  suddenly,  all  these  symptoms  are 
speedily  manifested,  and  should  it  happen  at  an  early  stage,  they  are  shortly 
carried  to  the  highest  degree,  or  even  may  soon  prove  fatal,  for  their  per- 
sistence may  give  rise  to  so  great  a  distention  of  the  bladder,  as  to  produce 
its  rupture.1  Agaiu,  the  accumulation  of  fecal  matters  in  the  intestine 
occasions  so  imperious  a  feeling  of  tenesmus,  that  the  female  gives  way  to 
the  most  immoderate  strainings;  and  the  pain  caused  by  the  displaced  and 
inflamed  uterus  may  create  a  convulsive  agitation  of  the  abdominal  muscles 
and  the  vaginal  walls,  so  great  as  to  cause  a  rupture  of  the  vagina,  and  an 
escape  of  the  fundus  of  the  uterus  from  the  vulva ;  as  happened  in  the  case 
communicated  to  M.  Dubois,  by  M.  Mayor. 

["Palpation  of  the  abdomen,"  says  M.  Salmon,  "is  usually  tlie  first  thing 
resorted  to  by  physicians  when  called  to  a  case  of  retroversion.  The  patients 
generally  both  know  and  say  that  they  are  pregnant,  so  that  when  the  abdomen  is 
examined  in  order  to  ascertain  the  cause  of  suffering,  a  large  tumor  reaching  from 
the  pubis  to  the  umbilicus  is  almost  always  detected.  This  tumor  is  superficial, 
fluctuating,  and  dull  upon  percussion.  It  may  bear  no  inconsiderable  resemblance 
to  the  uterine  globe,  especially  should  it  harden  at  intervals,  as  in  one  case  which 
came  under  our  notice.  That  the  tumor  is  formed  by  a  greatly  distended  bladder, 
.s  proved  by  the  use  of  the  catheter:  it  is  important,  however,  not  to  be  deceived 
by  the  statements  of  patients,  who  often  believe  that  the  bladder  is  empty  because 
they  are  able  to  discharge  a  small  quantity  of  water. 

"  Palpation  of  the  abdomen  is  also  useful  in  those  rare  cases  unaccompanied  by 
a  distended  bladder ;  for  here  the  displacement  of  the  uterus  is  indicated  by  the 
impossibility  of  deteoting  the  fundus  of  the  organ  on  a  level  with  or  below  the 
superior  strait  of  the  pelvis."     (Salmon.)] 

The  vaginal  examination,  in  such  cases,  will  enable  us  to  detect  the  par- 
ticular variety  of  displacement  which  causes  the  symptoms,  for  the  finger 
encounters  a  tumor  just  within  the  vagina  that  fills  the  whole  excavation, 
which  is  the  posterior  surface  of  the  womb.  In  passing  over  this  surface, 
which  is  of  greater  or  less  extent  according  to  the  stage  of  pregnancy,  the 
finger  reaches  the  fundus  of  the  uterus,  which  it  finds  directed  toward  the 
anterior  surface  of  the  sacrum,  and  in  more  serious  cases  toward  the  point 
of  the  coccyx.  Pursuing  the  examination  anteriorly,  the  neck  is  discov- 
ered to  be  turned  directly  forward,  toward  the  middle  of  the  posterior  sur- 
face of  the  pubis,  and  sometimes  even  raised  above  the  upper  edge  of  the 
symphysis.  The  displacement  may  indeed  be  so  great  that  the  axis  of  the 
organ  is  almost  completely  overturned  and   the  finger  cannot  reach  the 

1  The  greatly  distended  bladder  may  then  doubtless  form  a  very  considerable  tumor, 
capable  of  increasing  the  retroversion  mechanically,  and  of  opposing  the  reduction. 
But  the  very  intimate  adhesions,  by  which  the  anterior  and  posterior  surfaces  of  the 
uterus  are  connected  with  the  posterior  and  inferior  walls  of  the  bladder,  tend  espe- 
cially to  augment  the  difficulties.  The  abnormal  size  of  the  latter  organ  keeps  it  very 
high  in  the  pelvis,  and  the  neck  of  the  uterus  evidently  can  only  be  brought  down- 
wards and  backwards,  after  the  relieved  bladder  has  itself  descended  iuto  the  exca- 
vation. 


DISEASES    OF    PREGNANCY.  535 

external  orifice.  Sometimes,  however,  the  neck  is  very  accessible  to  the 
(ouch,  although  the  retroversion  is  carried  to  the  greatest  extent.  This  is 
owing  to  the  fact  of  the  cervix  being  bent  round  on  the  body,  like  tie  beak 
of  a  retort.  In  this  case,  the  uterus  was  retrofitted  before  being  overset 
backward. 

In  retroversion,  a  rounded  turaor,  varying  in  size  with  the  volume  of  the 
displaced  organ,  is  found  in  the  vagina.  This  tumor  spreads  out  more 
behind  than  in  front,  whereby  the  posterior  vaginal  wall  is  depressed,  whilst 
the  anterior  is  distended  and  elevated.  Sometimes  the  perineum  is  promi- 
nent, and  the  vulva  swollen,  the  rectum  is  pressed  down  and  almost  oblit- 
erated by  the  tumefied  organ,  and  the  anus  often  dilated  and  bulged 
outwards. 

[Unpleasant  to  the  patient  as  is  examination  by  the  rectum,  it  must  be  had  re- 
course to  when  the  indications  derived  from  the  above  described  measures  lead 
one  not  merely  to  suspect,  but  to  feel  certain  that  the  retroversion  exists.  It  is 
the  only  method  by  which  the  uterine  tumor  can  be  explored  over  a  considerable 
extent  of  surface,  as  there  is  nothing  to  prevent  the  finger  from  passing  deeply 
behind  it.  Another  advantage  is,  that  whilst  the  vaginal  touch  enables  us  to 
appreciate  better  the  position  of  the  cervix  at  the  bottom  of  the  long  cul-de-sac, 
behind  the  pubis,  examination  by  the  rectum  affords  precise  knowledge  of  the 
character  of  the  tumor  formed  by  the  fundus  of  the  womb.     (Salmon.)] 

A  particular  variety  of  retroversion  has  been  described  by  M.  Martin, 
of  Lyons,  in  which  the  os  tincse  protrudes  from  the  vulva,  and  the  fundus 
uteri  is  pushed  to  the  side  of  the  sacrum  ;  the  uterine  neck,  being  curved 
like  the  spout  of  a  ewer,  is  situated  below  and  a  little  in  front  of  the  pubis ; 
the  body  of  the  organ  is  retained  in  the  sacral  excavation,  and  lies  close  to 
the  perineum.  But,  after  carefully  reading  his  description,  I  do  not  think 
it  can  be  justly  considered  as  a  new  example  of  retroversion.  I  believe  it 
was  merely  a  falling  of  the  womb,  which  had  existed  prior  to  pregnancy 
and  had  been  aggravated  by  this  latter  condition;  there  was  at  the  sam- 
time  an  anteflexion  of  the  neck,  which  explains  how  the  curve  in  the  latter 
described  by  M.  Martin,  might  be  formed  below  and  in  front  of  the  pubis 
from  the  depressed  body  forcing  it  beyond  the  vulva. 

A  retroversion  could  scarcely  be  confounded  with  simple  prolapsus;  for, 
in  the  former,  the  vaginal  wall  is  always  situated  between  the  finger  and 
the  tumor,  and  the  neck  is  high  up  behind  the  pubis,  whilst,  in  a  prolapsus, 
the  cervix  is  always  the  most  dependent  part,  and  the  tumor  can  be  perfectly 
isolated  from  the  vagina ;  in  the  latter  ease,  the  reduction  is  generally  easy, 
but  it  is  usually  quite  difficult,  sometimes  even  impossible,  in  the  former. 
Further,  the  symptoms  of  retroversion  are  ordinarily  much  more  severe 
than  those  of  prolapsus. 

[Without  going  into  any  detail  on  the  subject,  we  would  point  out  the  possibility 
of  mistaking  a  retrovertod  pregnant  uterus  for  an  infra-uterine  fibrous  tumor, 
abdominal  tumors,  or  tumors  of  the  cavity  of  the  pelvis.  The  differential  diagnosis 
between  the  unimpregnated  uterus  when  rotroverted  and  the  same  organ  when 
similarly  displaced  during  pregnancy  may  also  prove  somewhat  difficult;  still, 
the  fad  of  the  case  may  he  generally  arrived  at  by  judging  carefully  of  the  Bize 
of   the  womb,  and    interrogating    the   patients   in    regard    to   the    time  of   the   last 


536  PATHOLOGY    OF    PREGNANCY. 

menstrual  flow.  It  would  be  easier  to  make  a  mistake  in  cases  of  extra-uterine 
pregnancy  developed  in  the  utero-rectal  cul-de-sac,  or  of  retro-uterine  hematocele  ; 
in  this  case,  however,  the  entire  uterus  is  crowded  out  of  position  without  being 
tilted,  and  it  is  often  easy  to  feel  its  contour  above  the  margin  of  the  pubis.] 

As  a  general  rule,  the  prognosis  in  these  displacements  is  very  grave  ;  it 
varies,  however,  with  the  period  of  pregnancy,  the  volume  of  the  uterus, 
the  alteration  in  the  neighboring  parts,  and  the  violence  of  the  attendant 
symptoms. 

Ceteris  paribus,  a  retroversion  is  usually  more  unfavorable  than  an  ante- 
version  ;  because,  in  retroversion,  the  constipation  and  retention  of  urine, 
which  thus  far  have  been  considered  as  comparatively  unimportant,  soon 
become  aggravating  circumstances  of  the  disease.  In  fact,  the  bladder  can 
only  enlarge  and  ascend  into  the  abdominal  cavity,  by  pushing  the  uterine 
neck  upwards  and  towards  the  front ;  and  hence,  its  body  acting  on  the 
Uterus  by  its  size  and  weight,  necessarily  increases  the  displacement.  The 
Ptercoraceous  matters  accumulated  in  the  rectum,  above  the  part  in  contact 
with  the  fundus  uteri,  act  in  a  similar  manner;  and,  again,  all  the  woman's 
expulsory  efforts  have  a  constant  tendency  to  further  depress  the  fundus, 
after  the  displacement  has  once  commenced.  In  anteversion,  on  the  con- 
trary, all  the  causes  just  enumerated  operate  in  a  favorable  manner.  Thus, 
the  distended  bladder  constantly  has  a  tendency  to  press  back  the  body  of 
the  womb,  which  is  then  carried  forwards,  and  the  accumulated  matters  of 
the  large  intestine,  pressing  from  above  downwards  on  the  posterior  part  of 
the  neck,  contribute  to  the  same  end. 

[Sudden  retroversion  is  more  threatening  in  appearance  than  the  gradual  form. 
Both  cases  are  serious  in  proportion  as  the  pregnancy  is  in  a  more  advanced  stage, 
because  the  accidents  which  are  liable  to  occur  and  the  difficulty  of  reduction, 
increase  with  the  size  of  the  uterus.  Independently  of  the  accidental  or  gradual 
cause  which  produced  it,  and  of  the  period  of  gestation  at  which  it  occurred,  the 
danger,  says  M.  Salmon,  is  in  proportion  to  the  importance  acquired  by  one  of 
the  principal  phenomena  of  the  affection,  viz.,  retention  of  urine.  If  the  latter  be 
complete,  the  symptoms  become  urgent  in  seven  or  eight  hours,  but  if  incomplete, 
the  displacement  may  continue  for  fifteen,  twenty,  or  twenty-five  days  without 
Causing  any   serious  results. 

Retroversion  generally  terminates  in  recovery,  though  it  may  give  rise  to  abortion. 
In  some  cases  death  may  ensue  from  peritonitis,  beside  which  rupture  or  gangrene 
of  the  bladder,  or  rupture  of  the  uterus  or  its  partial  destruction  by  gangrene,  may 
be  apprehended. 

Treatment.  —  In  the  first  place  the  bladder  must  be  emptied,  as  in  its  distended 
condition  it  would  interfere  with  the  attempts  at  reduction.  It  sometimes  happens, 
indeed,  that  after  the  urine  is  withdrawn,  reduction  occurs  spontaneously.  Many 
practitioners  have  very  justly  insisted  upon  the  advantage  of  catheterism  repeated 
several  times  daily  through  the  course  of  several  days,  as  the  only  method  of  treat- 
ment ;  it  bas  very  often  proved  successful,  insomuch  that  Burns  felt  authorized  to  say 
that  retroversion  would  rarely  last  over  a  week,  if  the  bladder  were  emptied  three  or 
four  times  a  day.  It  is  a  course,  therefore,  which  may  be  followed  whenever  the 
symptoms  are  not  urgent.] 

Treatment. — After  having  emptied  the  bladder  and  rectum,  and  combated 
the  inflammatory  symptoms  by  the  appropriate  means,  the  accoucheur  should 
proceed  at  once  to  reduce  the  uterus  to  its  natural  position,  and  sec  ire  it 


DISEASES    OF    PREGNANCY.  537 

there.  The  best  position  for  the  female  to  assume  is  one  in  which  all  the 
muscles  are  thrown  into  a  state  of  relaxation ;  two  fingers  are  then  to  be 
ntroduced  into  the  vagina,  with  which  the  body  is  first  to  be  pushed  up, 
ifter  which  the  index  should  be  hooked  over  the  neck  so  as  to  depress  it. 

The  reduction  may  sometimes  be  effected  on  a  single  trial,  but  usually  we 
are  compelled  to  repeat  the  attempt  after  an  interval  of  a  few  minutes  :  and 
just  at  the  instant  of  the  resumption  of  its  ordinary  position  by  the  womb, 
a  noise  is  heard,  in  some  instances,  like  the  click  of  a  spring.  It  must  not 
be  supposed,  however,  that  this  operation  is  always  an  easy  one.  For  the 
difficulty  in  using  the  catheter,  so  often  experienced,  the  impossibility  of 
jmptying  the  rectum,  and  especially  the  voluminous  tumor  formed  behind 
lie  uterus  by  the  faeces  collecting  in  the  sigmoid  flexure  of  the  colon,  the 
violent  strainings  made  by  the  patient  under  such  circumstances,  and  the 
size  of  the  tumor,  and  its  adhesions  to  surrounding  parts,  are  so  many  em 
barrassing  circumstances  to  the  practitioner.  Although  it  is  very  seldom 
that  we  cannot  succeed  in  introducing  the  catheter,  by  time  and  patience, 
yet  in  some  cases  this  has  been  found  altogether  impossible ;  indeed,  much 
prudence  is  requisite  in  the  measures  then  adopted,  and  if  they  all  prove 
useless,  a  moderate  pressure  made  over  the  hypogastrium  may,  perhaps, 
slowly  compress  the  bladder,  and  thus  make  the  woman  urinate,  so  to  speak, 
by  disengorgement. 

The  retroverted  fundus  sometimes  compresses  the  rectum  to  such  a  degree 
that  an  injection  cannot  be  made  to  enter  the  large  intestine. 

Such  cases  demand  some  precaution  in  the  administration  of  the  enemata. 
There  may  be  a  collection  of  indurated  matters  above  the  fundus  of  the 
retroverted  uterus,  in  which  case  it  is  evident,  that,  as  the  latter  compresses 
the  upper  part  of  the  rectum,  an  injection  given  in  the  usual  manner  cannot 
reach  high  enough  to  bring  away  the  faeces  accumulated  in  the  descending 
colon.  It  then  becomes  necessary  to  use  a  long  gum-elastic  tube,  which  may 
be  inserted  to  the  extent  of  seven  or  eight  inches.  This  simple  expedient 
has  often  disencumbered  the  intestine  of  matters  which  an  ordinary  injection 
could  not  have  reached,  with  the  effect  of  producing  spontaneous  reduction. 

Even  with  the  use  of  the  tube  just  recommended,  the  injections  are  some- 
times ineffectual.  In  such  cases,  if  the  palpation  and  the  abdominal  percus- 
sion lead  us  to  suspect  a  considerable  accumulation  of  fecal  matters  in  the 
descending  colon,  we  should  exhibit  purgatives  by  the  mouth.  Again,  the 
necessary  introduction  of  the  hand  into  the  vagina,  to  effect  the  reduction, 
is  at  times  so  painful  to  the  female,  that,  notwithstanding  all  persuasions  to 
the  contrary,  she  gives  way  to  the  most  violent  bearing-down  efforts,  which 
neutralize  those  of  the  operator.  If  baths,  or  emollient  and  narcotic  injec- 
tions, should  not  assuage  this  acute  sensibility,  the  advice  of  Dewees  s/.ight 
oe  taken,  and  bleeding  practised  to  the  extent  of  producing  syncope;  still 
better,  in  my  opinion,  would  be  the  administration  of  chloroform  befoie  the 
operation. 

The  abnormal  adhesions  that  are  occasionally  established  between  the 
uterus  an  1  adjacent  parts,  will  certainly  add  another  to  the  serious  difficulties 
just  mentioned  ;  but  even  this  should  not  give  rise  to  despair.  Aroussat 
reports  a  case  where  he  distinctly  felt  some  bridles  in   the  bottom  pf  the 


538  PATHOLOGY    OF     PREGNANCY. 

vagina,  and  to  the  left  of  the  tumor,  into  which  he  could  ho  k  the  forefinger, 
but  after  a  careful  examination  he  acquired  the  conviction  that  the  uterus 
was  free  on  the  right  side.  He  then  renewed  his  attempts,  by  acting  in  such 
a  way  as  to  turn  the  uterus  from  the  opposite  side  towards  that  where  the 
adhesions  existed ;  that  is,  from  right  to  left,  and  he  thereby  succeeded  in 
replacing  the  orpm  in  its  natural  position.  But  if,  after  having  adopted  all 
suitable  precautions,  the  simple  procedure  just  described  should  not  succeed, 
one  of  the  following  plans  should  then  be  resorted  to,  namely,  to  act  simul- 
taneously by  the  vagina  and  rectum,  as  some  have  advised;  but  the  most 
simple  plan,  however,  is  that  of  M.  Evrat,  quoted  by  M.  Moreau,  as  follows: 
The  woman  must  lie  upon  her  side,  and  the  accoucheur  then  takes  a  rod 
eight  or  ten  inches  long,  covered  at  one  end  by  a  tampon  of  linen  smeared 
over  with  some  fatty  matter,  which  he  introduces  into  the  rectum  so  as  to 
press,  through  the  recto-vaginal  septum,  the  fundus  uteri  from  below  upwards, 
whilst  the  two  fingers  passed  into  the  vagina  hook  the  neck,  and  simultane- 
ously draw  it  downwards  and  backwards.  The  force  necessary  for  this 
reduction  is  very  variable,  though  in  effecting  it  we  need  not  be  restrained 
by  the  fear  of  producing  an  abortion ;  for,  even  if  this  were  to  result  from 
such  efforts,  the  dangers  to  the  mother  would  be  far  less  than  from  the  con- 
tinuance of  the  retroversion.  In  a  case  of  this  kind,  M.  Halpin,  after  having 
emptied  the  bladder,  and  endeavored  unsuccessfully  to  reduce  the  uterus, 
came  to  the  conclusion  that  the  only  mode  of  curing  the  patient  was  by  the 
employment  of  an  instrument  that  would  bear  equally  on  all  parts  of  the 
displaced  womb  ;  and  he  imagined  that  the  pelvis  could  be  filled  up  with  a 
bladder,  and  thus  all  the  contained  organs  be  pressed  up  together  into  the 
abdomen.  With  this  view,  he  placed  an  empty  one  between  the  fundus 
uteri  and  the  rectum,  and  then  by  cautiously  distending  it,  he  actually  suc- 
ceeded in  pushing  the  fundus  upwards. 

Attributing,  as  they  did,  the  difficulty  of  reduction  to  the  pressure  of  the 
viscera  upon  the  anterior  surface  of  the  uterus,  Hunter,  Boyer,  and  others, 
have  recommended  that  the  patient  should  be  placed  in  such  a  position  that 
the  weight  of  the  intestines  may  be  supported  by  the  upper  part  of  the 
abdomen.  Acting  upon  this  suggestion,  M.  Godefroy  adopts  the  following 
position  :  the  patient  rests  her  head  and  hands  upon  the  floor,  whilst  the 
anterior  part  of  the  thighs  and  legs  repose  upon  the  edge  of  the  bed,  when* 
they  are  supported  by  assistants.  The  surgeon  then  acts  either  through  the 
vagina  or  the  rectum  upon  the  fundus  of  the  uterus  in  such  a  way  as  to  effect 
the  reduction.  In  three  very  grave  cases,  success  was  complete.  (Journ. 
dcs  Conn.  Med.  Chir.,  August,  184G.) 

This  position  is  very  fatiguing,  painful,  and  disagreeable  to  the  patient. 
I  would,  therefore,  much  prefer,  in  these  difficult  cases,  simply  to  place  the 
female  on  her  knees  in  bed,  with  the  upper  part  of  the  body  supported  on 
the  elbows.  I  have  thus  been  aide,  in  two  cases,  to  reduce  retroflexions 
which  had  resisted  every  other  means. 

In  an  obstinate  case,  Ave  might  resort  to  a  procedure  recently  employed 
by  Amussat,  with  a  prospect  of  success  :  that  is,  to  place  the  female  in  the 
position  for  operating  for  stone,  and  then  introduce  one  or  two  fingers  into 
the  rectum,  and  gently  press  up  the  uterine  tumor,  by  following  the  con- 


DISEASES    OF    PREGNANCY.  539 

cavity  of  the  sacrum,  at  first  directly  upwards,  and  then  alternating  from 
right  to  left  and  left  to  right,  so  as  to  raise  the  whole  surface  of  the  uterus , 
but  if  the  finger  or  fingers  placed  in  the  rectum  cannot  reach  so  high,  the 
thumb  should  be  put  into  the  vagina  so  as  to  elevate  the  perineum,  in  order 
that  the  former  may  penetrate  still  further ;  and,  lastly,  to  get  higher  yet, 
an  assistant  might  press  against  the  elbow,  or  the  accoucheur  himself  could 
sustain  it  with  his  own  thigh  or  body.  M.  Amussat  declares  that  he  has 
twice  succeeded  in  this  manner  in  making  a  reduction  that  had  previously 
been  ineffectually  tried  by  several  other  practitioners. 

Finally,  what  is  to  be  done  where  the  reduction  is  impossible  ?  Abandon 
the  patient  to  the  resources  of  nature,  says  Merriman ;  but  would  not  that 
devote  her  to  a  certain  death,  in  case  the  inflammatory  phenomena  did  not 
determine  an  abortion?  And  since  a  miscarriage  is  inevitable  under  the 
most  fortunate  circumstances,  would  it  not  be  advisable  to  bring  it  on, 
rather  than  to  leave  the  patient  exposed  for  a  long  time  to  the  dangers 
which  threaten  her?  Indeed,  most  physicians  are  of  this  opinion,  and  I 
should  not  hesitate,  therefore,  to  rupture  the  membranes  by  a  sound  passed 
through  the  neck  of  the  womb.  But,  sometimes,  the  neck  is  so  high  up 
that  it  is  wholly  inaccessible;  and  then  a  puncture  of  the  uterus  itself  must 
be  resorted  to.  This  latter  operation  has  been  performed  both  by  the  va- 
gina and  by  the  rectum,  but  I  should  think  the  first  preferable.  It  is,  without 
doubt,  the  last  resource,  but  always  ought  to  be  chosen  rather  than  the 
symphysiotomy  recommended  by  Gardien  and  some  other  accoucheurs. 

After  the  reduction  (when  that  has  been  possible),  the  patient  must  re- 
main in  the  horizontal  position  until  towards  the  sixth  month  of  pregnancy, 
and  must  carefully  avoid  all  straining,  whether  in  urinating  or  at  stool. 
These  simple  precautions  are  all-sufficient,  and  generally  render  the  intro- 
duction of  a  pessary  useless ;  which  latter,  however,  Baudelocque  considers 
indispensable  in  most  cases.  Occasionally,  the  incontinence  of  urine,  brought 
on  by  the  pressure  which  the  neck  of  the  bladder  has  suffered  from  the  neck 
or  fundus  uteri,  may  still  continue  some  time  after  the  reduction ;  and  then, 
if  the  ordinary  simple  means  do  not  cause  its  disappearance,  we  may  resort 
to  the  warm  mineral  waters  of  Cauterets,  Bareges,  or  Balaruc ;  to  frictions 
with  the  tincture  of  cantharides,  and  blisters  on  the  hypogastrium,  together 
with  tonics  and  astringents  administered  internally. 

§  3.  Anteversion. 

Anteversion  is  very  rare  in  the  early  stages  of  gestation,  and,  probably  on 
this  account,  has  been  passed  over  by  most  authors  who  have  studied  the 
disorders  of  pregnancy.  The  manner  in  which  the  uterus  is  developed,  the 
peculiar  form  of  the  anterior  and  posterior  boundaries  of  the  pelvis,  and  the 
normal  direction  of  the  organ,  are  so  many  circumstances  which,  just  in 
proportion  as  they  facilitate  retroversion,  render  the  occurrence  of  antever- 
sion difficult.  Besides,  the  influence  which  a  distended  rectum  and  bladder 
have  in  the  production  and  increase  of  the  posterior  displacement,  would 
tend  to  restore  the  womb  to  its  natural  position,  should  any  circumstance 
effect  a  commencement  of  anteversion. 

Notwithstanding  these  favorable  conditions,  anteversion  has  been  observed 


540  PATHOLOGY    OF   PREGNANCY. 

by  Chopart  ai;  tvo  months,  by  Madame  Boivin  at  three  mouths,  and  finally 
by  Ashwell.  The  case  of  the  latter  being  unknown  in  France,  we  shall 
give  an  analysis  of  it.  I  have  myself  twice  detected  it  at  two  months  in 
cases  of  women  affected  with  incorrigible  vomiting. 

Mrs.  M ,  thirty-three  years  of  age,  and  habitually  very  constipated, 

fell,  during  the  first  month  of  her  pregnancy,  whilst  descending  a  pair  of 
etairs.  Though  there  was  no  hemorrhage,  she  had  a  spell  of  faintness  which 
lasted  nearly  an  hour.  For  five  or  six  weeks  there  was  a  feeling  of  weight 
at  the  pubis,  micturition  was  frequent  and  painful,  but  there  was  no  ob- 
struction to  defecation.  I  examined  her  for  the  first  time  at  the  end  of  the 
second  month.  The  cervix  was  in  its  normal  position,  but  the  strongly- 
inclined  fundus  formed  a  round  solid  tumor  between  the  bladder  and  the 
anterior  part  of  the  vagina.  Pressure  with  the  finger  upon  the  angle  of 
inflexion  caused  pain.  The  neck  w'as  elongated,  and  larger  and  harder 
than  usual.  I  endeavored,  ineffectually,  to  effect  reduction  by  pressing 
upon  the  fundus  of  the  womb  with  the  finger,  whilst  the  neck  was  drawn 
downward  and  forward  by  the  index  of  the  right  hand.  At  the  sixth 
month,  the  husband  found  that  the  anteflexion  had  almost  entirely  disap- 
peared, and  although  the  lady  still  suffered  some  pain  in  the  latter  months, 
she  was  delivered  without  difficulty. 

Although  the  author  describes  this  as  a  case  of  anteflexion,  it  is  evident 
that  there  was  also  anteversion,  as  is  proved  by  the  normal  position  of  the 
neck,  and  especially  by  the  spontaneous  disappearance  of  the  displacement 
at  the  fourth  month.  I  see,  indeed,  no  reason  why  an  anteflexion  should 
disappear  suddenly  at  this  stage  of  pregnancy. 

Anteversion  is,  therefore,  possible  in  the  early  months,  though  it  occurs 
more  frequently  in  the  second  half,  and  especially  towards  the  end  of  the 
pregnancy.  At  that  time,  the  fundus  of  the  womb,  which  is  naturally  in- 
clined forwards,  is  supported  by  the  abdominal  muscles  only ;  now  if  these 
resist  slightly,  as  often  happens  when  women  have  had  several  children,  the 
physiological  inclination  has  a  constant  tendency  to  increase.  The  axis  of 
the  uterus  may  thus  become  nearly  horizontal,  or  even  be  depressed  still 
loAver,  until  the  fundus  falls  upon  the  thighs  and  knees.  The  neck,  which 
is  carried  very  far  upwards  and  backwards,  sometimes  gets  above  the  sacro- 
vertebral  angle,  and  is  reached  by  the  finger  with  the  greatest  difficulty ; 
the  impossibility  of  attaining  it  has  occasionally  given  rise  to  a  belief  of  the 
existence  of  imperforation. 

Beside  the  signs  furnished  by  the  touch  and  examination  of  the  abdomen, 
some  functional  disorders  may  be  produced  by  anteversion  at  different  stages 
of  pregnancy,  whose  cause  should  not  be  mistaken  when  called  upon  to 
treat  them.  In  the  early  months,  the  sensation  as  of  a  heavy  weight  at  the 
pubis,  frequent  and  sometimes  painful  micturition  and  defecation,  are  almost 
the  only  rational  signs.  In  the  latter  months,  the  weight  of  the  uterine 
tumor,  which  is  carried  strongly  forwards,  occasions  pains  and  draggings  in 
the  thighs  and  groins;  the  extreme  distention  of  the  skin  of  the  abdomen, 
also,  produces  acute  pain,  and  the  pressure  to  which  the  bladder  is  subjected 
is  the  cause  of  vesical  tenesmus,  with  dysuria  or  strangury.  Finally,  in  the 
worst  cases,  walking  is  rendered  difficult  and  often  impossible. 


DISEASES    OF    PREGNANCY.  541 

The  prognosis  is  not  generally  serious;  for,  when  the  anteversion  occurs 
in  the  early  months,  the  development  of  the  uterus  may  restore  it ;  when  it 
occurs  in  the  second  half  of  gestation,  it  may  produce  premature  labor, 
though  it  usually  occasions  merely  the  inconveniences  just  spoken  of,  and 
never  gives  rise  to  accidents  in  any  degree  serious,  except  during  labor. 
(See  Dystocia.) 

Reduction  may  be  attempted  in  the  early  months,  but  has  hitherto  always 
failed;  too  great  perseverance  would  be  at  the  risk  of  abortion.  The  most 
prudent  course,  therefore,  provided  resistance  is  encountered,  is  to  intrust 
the  reduction  to  the  subsequent  progress  of  the  pregnancy.  If  the  discom- 
fort and  weight  are  too  fatiguing,  they  may  be  relieved  by  the  horizontal 
decubitus. 

At  a  more  advanced  stage,  a  body  bandage,  or  a  sort  of  corset  or  belt  for 
the  abdomen,  well  adapted  to  the  size  and  form  of  the  belly,  will  afford 
much  relief.  When  the  abdomen  is  pendent,  the  abdominal  belt  may  be 
kept  up  by  suspenders. 

§  4.  Lateral  Obliquities. 

In  describing  the  physiological  phenomena  of  pregnancy,  we  spoke  of 
obliquities  of  the  uterus,  and  pointed  out  their  probable  causes.  They  are 
rarely  carried  to  any  great  extent,  and  are  never  the  occasion  of  serious 
accidents.  Only  by  tending  to  produce  an  unfavorable  presentation  of  the 
child,  and  by  retarding  the  dilatation  of  the  neck,  can  they  have  any  un- 
pleasant effect  upon  the  labor.  Therefore,  the  present  is  not  the  proper 
time  to  speak  of  them  further. 


CHAPTER  III. 

DISEASES   OF   THE   OVUM. 

ARTICLE  I. 

DROPSIES. 

§  1.  Dropsy  of  the  Amnion,  (Hydramnioa.) 

The  amniotic  liquid  may  sometimes  augment  to  a  very  considerable 
quantity ;  but,  as  the  normal  amount  is  very  variable,  it  is  difficult  to  say 
above  what  limits  it  should  be  considered  as  a  disease;  however,  when  it 
exceeds  three  or  four  pounds,  the  accumulation  may  be  justly  attributed  to 
some  morbid  condition. 

In  the  present  state  of  our  science,  it  would  be  absolutely  impossible  to 
designate  the  cause  of  this  singular  affection,  although  some  facts  seem  to 
militate  in  favor  of  its  being  produced  by  an  inflammation  of  the  amnion  ; 
but  this  opinion  requires  further  confirmation  to  be  received  without  hesita- 
tion, for,  notwithstanding  Dr.  Mercier  claims  to  have  seen  the  internal  sur- 
face of  the  amnion  covered  several  times  by  false  membranes,  and  the 
membrane  itself  highly  injected,  yet  other  observers  have  not  detected  any- 
thing of  the  kind.     (Journ.  GOn.  de  Mod.,  torn,  xiv.) 

Again,  from  the  cases  cited  by  Drs.  Merriman  and  Lee,  it  would  appear 


542  PATHOLOGY    OF    PREGNANCY. 

that  a  dropsy  of  the  amnion  is  often  associated  with  a  morbid  condition  ot 
a  bad  conformation  of  the  foetus,  or  with  a  state  of  general  infiltration  on 
the  part  of  the  mother;  indeed,  Stme  facts  would  lead  to  the  supposition 
that  constitutional  syphilis  predisposes  to  this  disease. 

In  a  few  instances,  it  has  seemed  referable  to  sanguineous  plethora ;  but 
as  it  occurs  in  women  of  every  variety  of  condition,  constitution,  and  age, 
this  cannot  be  considered  as  a  fixed  rule  on  this  point.  It  is  much  more 
frequent  in  twin  pregnancies,  and  rarely  supervenes  prior  to  the  fifth  month. 

In  some  cases,  the  dropsy  is  preceded  by  all  the  signs  of  an  active  in- 
flammation ;  but  most  commonly  a  dull  pain  in  the  uterus,  a  feeling  of 
weight  about  the  pelvis,  and  a  rapid  growth  of  the  organ,  are  the  only  evi- 
dences of  its  existence.  The  womb  speedily  acquires  a  considerable  volume, 
and  is  more  distended  at  the  fifth  or  sixth  month  than  it  usually  is  at  term. 
Further,  the  development  is  proportionate  to  the  quantity  of  liquid  :  thus, 
the  latter  often  amounts  to  five  or  six  pints;  and  Baudelocque  reports  a 
case  in  which  thirteen  pints  escaped  from  the  uterus,  and  another  one  of 
thirty-two  pints.  Certain  authors  have  even  known  forty  or  fifty  pints  to 
exist  in  the  amniotic  cavity.  The  fluid  is  similar  in  all  respects  to  the 
liquor  amnii. 

The  uterus  rarely  becomes  much  enlarged  without  disturbing  the  func- 
tions of  the  thoracic  organs  in  the  manner  heretofore  described,  and  facts 
are  not  wanting  to  prove  that  it  may  even  produce  asphyxia. 

In  a  case  reported  by  Duclos,  the  distention  of  the  womb  was  so  great, 
although  the  gestation  had  only  advanced  to  the  seventh  month,  that  it  en- 
larged the  abdomen  beyond  measure,  pushed  up  the  diaphragm,  and  inter- 
fered so  much  with  the  respiration  and  circulation  that  the  woman's  life 
seemed  to  be  seriously  compromised. 

The  physicians,  called  in  consultation,  decided  in  favor  of  bringing  on 
the  uterine  contractions  as  soon  as  the  neck  showed  any  evidence  of  dilata- 
tion ;  but,  suffocation  being  imminent,  M.  Duclos  ruptured  the  membranes, 
at  first  permitting  a  certain  quantity  of  fluid  to  escape,  then,  by  keeping  his 
fingers  in  the  neck,  he  prevented  its  complete  evacuation;  and  thus,  for 
four  times,  after  intervals  of  fifteen  minutes  each,  he  allowed  a  further  flow, 
while  slight  pressure  was  made  over  the  abdomen.  In  this  manner,  fourteen 
pounds  were  collected,  without  counting  what  was  lost.  The  symptoms  dis- 
appeared immediately,  but  as  the  uterus  did  not  appear  capable  of  any 
effort,  and  the  neck  offering  no  resistance,  it  was  easily  dilated,  and  a  living 
infant  brought  away  by  the  forceps.  The  child  was  feeble  and  diminutive, 
and  its  limbs  were  very  small.     The  mother  recovered. 

M.  Evrat,  Sen.,  of  Lyons,  has  published  several  cases  of  almost  complete 
asphyxia  (lividity  of  features,  cessation  of  pulse  and  respiration),  in  which 
the  women  were  rapidly  restored  by  the  puncture  of  the  membranes  and 
discharge  of  a  large  amount  of  water. 

A  premature  distention  of  the  uterus  by  amniotic  dropsy,  to  the  size 
which  it  usually  has  at  the  end  of  gestation,  is  capable  of  producing  dan- 
gerous symptoms.  It  is  astonishing,  as  Scarpa  remarks,  that  in  cases  of 
dropsy  complicating  pregnancy,  the  womb  should  occasion  symptoms  of 
suffocation  which  it  never  determines  at  the  end  of  the  ninth  month,  though 


DISEASES    OF   THE   OVUM.  543 

its  size  be  tie  same.  It  is  explained  by  the  sudden  and  rapid  development 
in  the  first  case  ;  whilst  in  the  latter  the  distention  takes  place  almost  im- 
perceptibly, the  walls  of  the  abdomen  yield  gradually,  thus  allowing  the 
uterus  to  project  more  in  front,  so  as  to  diminish  its  elevation  slightly,  whilst. 
it  crowds  much  less  upon  the  diaphragm. 

As  before  said,  ascites  often  coexists  with  the  amniotic  dropsy ;  but  as  the 
I  wo  diseases  may  occur  separately,  it  becomes  important  to  establish  their 
differential  diagnosis. 

In  ascites  complicating  pregnancy,  the  urine  is  small  in  quantity,  whitish, 
and  turbid,  the  thirst  great  and  constant,  and  the  lower  extremities  and 
genital  parts  mostly  much  infiltrated.  It  is  difficult  and  sometimes  even 
impossible  to  distinguish  the  shape  and  fundus  of  the  uterus,  on  account  of 
the  irregular  form  of  the  belly,  and  the  enormous  distention  of  the  hypo- 
chondriac regions.  Percussion  produces  an  undulation,  or  sort  of  fluctua- 
tion, which  is  much  more  perceptible  at  the  upper  than  at  the  lower  part 
of  the  abdomen. 

In  dropsy  of  the  amnion,  the  size  of  the  belly  approaches  much  more 
nearly  that  of  a  uterus  at  term,  although  the  pregnancy  may  not  have  ex- 
isted more  than  five  or  six  months.  The  uterus  is  so  rounded  as  to  be 
almost  spherical.  Fluctuation  is  more  obscure,  thirst  slight  or  absent,  urine 
natural,  and  in  some  cases  little  or  no  infiltration  of  the  lower  extremities. 
The  umbilical  tumor  is  rarely  present,  and,  when  it  exists,  has  not  the  trans- 
parency observed  in  ascites. 

The  great  enlargement  of  the  womb  often  provokes  premature  contractions 
and  abortion.  Sometimes  the  child  is  born  living,  but  so  little  developed 
that  it  cannot  survive ;  more  frequently,  it  dies  in  the  mother's  womb,  and 
is  not  expelled  until  some  time  after. 

Dropsy  of  the  amnios,  which  is  so  grave  as  regards  the  infant,  rarely  com- 
promises the  mother's  life,  or  even  her  health.  Some  unfortunate  cases 
have,  however,  proved  fatal,  though  generally  she  is  merely  incommoded  by 
the  excessive  volume  of  the  womb,  and  the  consequent  interference  with 
other  organs.  The  expulsion  of  the  liquid  is  generally  spontaneous ;  the 
foetus,  membranes,  and  placenta  passing  away  with  the  waters ;  whence,  the 
cause  no  longer  existing,  the  disease  is  completely  cured. 

According  to  some  authors,  the  rupture  of  the  membranes  and  consequent 
expulsion  of  the  fluid  is  not  always  followed  by  the  birth  of  the  child.  In 
this  case,  the  breach  in  the  membranes  takes  place  at  a  point  considerably 
above  the  neck,  the  uterus  is  relieved  slowly  of  the  superabundant  fluid,  and 
the  pregnancy  proceeds  with  no  other  accident  than  a  more  or  less  frequent 
lischarge  of  water.  I  think  that,  in  most  of  these  cases,  an  accumulation 
of  fluid  between  the  membranes  and  the  uterus,  as  in  the  hydrorrhea  to  be 
spoken  of  hereafter,  has  been  mistaken  for  amniotic  dropsy.  I  confess,  how- 
ever, that  the  following  case,  carefully  observed  by  Ingleby,  haves  hardly  a 
doubt  as  to  the  possibility  of  the  fact:  A  lady,  six  months  gone  in  her  third 
pregnancy,  lost  suddenly  a  large  quantity  of  water  during  the  night.  From 
this  moment,  until  the  termination  of  pregnancy,  there  escaped  every  two  or 
three  days  a  pint  and  a  quarter  of  fluid.  The  woman  was  delivered  of  a 
large  boy.     The  after-birth  was  expelled  spontaneously.     1   received  it  in 


:>  1  t  PATHOLOGY    OF    PREGNANCY. 

my  hand,  says  the  author,  so  as  to  avoid  laceration  of  the  membranes.  I 
examined  it  with  the  greatest  care,  and  discovered,  besides  the  opening  made 
by  the  head  in  the  centre  of  the  membranes,  a  second  opening,  of  cirenlar 
form,  near  the  edge  of  the  placenta.  It  was  doubtless  through  the  latter 
that  the  fluid  escaped  from  time  to  time. 

It  is  proved,  by  many  observations,  that  amniotic  dropsy  frequently  recu is 
in  the  subsequent  pregnancies  of  the  same  female. 

A  remarkable  circumstance,  pointed  out  by  MM.  Bunsen  and  Kill,  and 
one  instance  of  which  has  Come  under  my  own  notice,  is  a  dropsical  condition 
of  the  foetus,  it  being  sometimes  affected  with  hydrocephalus,  and  at  others 
with  ascites. 

The  same  authors  also  mention  having  observed  that  in  these  cases  the 
placenta  was  often  remarkably  large.  Thus,  in  a  case  reported  by  M.  Kill, 
in  which  the  extreme  distention  of  the  uterus  produced  abortion  at  the  sixth 
month,  the  circumference  of  the  placenta  was  a  third  larger,  and  its  thick- 
ness double  that  of  ordinary  placentas.  It  was  pale,  and  its  tissue  spongy, 
and,  when  divided,  the  vessels  traversing  its  substance  were  found  to  have 
almost  the  size  of  the  arteries  and  umbilical  vein. 

The  abdomen  of  the  fcetus  contained  a  large  amount  of  fluid.  The  liver 
was  voluminous,  occupying  almost  the  whole  abdominal  cavity.  Its  structure 
was  normal,  without  any  indication  of  swelling,  but  its  vessels  were  highly 
developed. 

This  great  size  of  the  liver  is  supposed  by  the  authors  quoted  to  be  con- 
nected with  the  extreme  development  of  the  placenta,  whose  enlarged  vessels 
would  of  course  supply  a  great  quantity  of  blood  to  the  umbilical  vein. 
(Churchill,  page  50.) 

When  the  malady  is  once  established,  it  is  exceeding  difficult  to  find  the 
proper  remedies, —  I  will  not  say  to  cure,  but  even  to  impede  its  course;  —  for 
instance,  diuretics  have  usually  proved  of  little  value.  Some  authors,  indeed, 
Beein  to  have  observed  good  effects  from  dry  diet ;  and  Burns  specially 
recommends  cold  bathing.  But,  in  spite  of  all  we  can  do,  the  affection 
ordinarily  goes  on  increasing  until  the  commencement  of  labor;  and  in  the 
greater  number  of  cases  there  is  nothing  to  be  done  except  to  await  this 
event.  However,  if  the  uterine  tumor  be  of  excessive  size,  more  especially 
should  the  dropsy  of  the  amnion  be  complicated  with  ascites  and  a  general 
infiltration,  and  the  patient's  life  be  endangered  by  the  obstructions  to  the 
haematosis,  an  evacuation  of  the  waters  should  be  determined  upon  by 
rupturing  the  membranes. 

The  puncture  is  usually  effected  by  the  use  of  a  male  or  female  catheter, 
or  a  stylet,  which  is  introduced  through  the  neck,  and  the  membranes  per- 
forated with  its  extremity.  When  the  cervix  is  sufficiently  dilated,  the 
rupture  maybe  performed  with  the  finger.  When  not  obliged  to  act  quickly, 
contractions  may  be  previously  solicited  by  introducing  and  leaving  a  piece 
of  prepared  sponge  in  the  cavity  of  the  cervix,  or  by  practising  some  douches 
upon  the  inferior  segment  of  the  uterus.  (See  Premature  Artificial  Delivery.) 
But  should  the  gravity  of  the  symptoms  demand  immediate  intervention, 
there  would,  I  think,  be  some  advantage  in  following  the  advice  of  M. 
Guillemot,  and  to  glide  the  catheter  between  the  ovum  and  the  uterus,  so  a? 


DISEASES    OF    THE    OVUM.  545 

to  pierce  the  membrane  far  above  the  neck  ;  this  process  would  permit  the 
discharge  of  the  fluid  to  be  controlled,  and  only  the  superabundance,  so  t< 
speak,  to  be  withdrawn.     The  pregnancy  may  afterward  be  left  to  itself. 

In  case  of  complete  obliteration  or'  the  neck,  paracentesis  by  the  vagina 
and  in  the  vicinity  of  the  uterine  orifice  must  be  performed.  Scarpa  aaJ 
Camper  recommend  puncturing  between  the  umbilicus  and  pubis.  In  one 
of  the  observations  of  Evrat,  Sen.,  the  operation  was  practised  in  the  place, 
so  called,  of  election,  for  paracentesis.  The  patient  was  delivered  eight  days 
afterward  of  two  living  children,  and  recovered  perfectly.  The  details  given 
by  the  author  do  not  inform  us  whether  the  case  was  one  of  ascites,  or  really 
of  amniotic  dropsy,  as  he  thought. 

The  vaginal  puncture  seems  to  me  likely  to  subject  both  mother  and  child 
to  the  fewest  risks,  whenever  the  neck  is  inaccessible. 

§  2.  Hydrorrhea,  (Hydrorrhoea  gravidarum:) 

The  Germans  have  given  this  name  to  those  discharges  of  water  that  occur 
in  the  course  of  the  gestation,  but  which,  in  general,  are  neither  preceded 
nor  followed  by  any  uterine  contractions ;  their  nature  is  such  as  to  interfere 
but  slightly  with  the  pregnancy,  the  latter  advancing  as  usual  to  term,  and 
at  the  accouchement  the  bag  of  waters  is  regularly  formed. 

This  affection  is  quite  common  in  the  latter  months,  but  very  rare  at  the 
beginning  of  gestation.  I  observed  it  once  between  the  third  and  fourth 
month,  and  it  reappeared  but  once  during  the  remainder  of  the  pregnancy, 
which  terminated  happily.     (See  Abortion,  article  Diagnosis.) 

The  frequency  of  such  discharges,  and  the  quantity  of  water  lost  each 
time,  are  exceedingly  variable  in  different  cases.  Sometimes  the  liquid 
comes  away  in  gushes,  at  others  drop  by  drop  ;  but  the  amount  may  increase 
in  an  incredible  manner,  and  the  loss  may  occur  but  once,  or  be  renewed 
frequently.  Further,  the  intervals  of  its  appearance  are  very  irregular,  and 
lasting  a  long  time  when  it  does  come  on,  during  which  any  mental  emotions 
or  bodily  excitement  singularly  influence  the  profuseness  of  the  discharge. 
On  the  other  hand,  it  augments  in  quantity  during  the  most  perfect  quietude, 
as,  for  instance,  at  night  during  sleep;  its  cause  can  rarely  be  ascertained. 

Most  generally,  the  female  enjoys  her  usual  health  before  the  discharge 
comes  on,  when  she  unexpectedly  finds  herself  wet,  the  fluid  escaping  drop 
after  drop,  or  else  she  hears  the  peculiar  sound  caused  by  the  sudden  irrup- 
tion of  a  considerable  quantity  of  the  waters.  In  most  cases,  she  suffers  no 
pain  either  pending  or  after  this  discharge;  though  it  may  happen  thai  a 
too  rapid  depletion  of  the  uterus,  and  the  consequent  parietal  retraction, 
may  bring  on  some  slight  uterine  contractions;  but  if  the  patient  then  keeps 
perfectly  still,  they  soon  disappear,  and  everything  resumes  its  natural  order. 
In  color,  the  discharged  water  is  usually  a  little  yellowish,  very  limpid,  and 
at  times  tinged  with  blood,  leaving  stains  upon  the  linen,  and  having  a  well- 
marked  spermatic  odor. 

Should  the  hydrorrhoea  be  attended  with  the  uterine  pains,  it  would  be 
an  evidence  of  an  approaching  abortion ;  and  some  accoucheurs,  supposing 
the  membranes  had  been  ruptured,  have  been  known,  under  such  circum- 
stances, to  use  every  effort  to  accelerate  and  to  terminate  a  laboi  *hicfo 
35 


546  PATHOLOGY  OF  PREGNANCY. 

really  had  not  commenced,  and  which,  without  their  interference,  would  not 
have  occurred  before  the  ordinary  period. 

[We  saw  a  case  of  hydrorrhea  during  the  sixth  month  of  gestation,  in  which 
uterine  contractions  had  come  on  and  almost  completely  effaced  the  neck  of  the 
womb  which  was  opened  to  the  size  of  about  a  franc-piece.  Rest  in  bed  and  opiate 
injections  quieted  the  threatening  of  abortion,  and  the  patient  was  delivered  at 
term.] 

This  error  may  be  avoided  by  attending  to  the  fact,  that,  notwithstanding 
so  considerable  a  flow  of  liquid,  the  size  of  the  uterus,  its  consistency  and 
elasticity,  are  such  as  it  generally  presents  at  that  period.  These  remarks 
will  at  least  be  sufficient  to  excite  a  doubt  as  to  the  true  source  of  the 
waters;  and  from  the  moment  that  there  is  a  doubt,  every  effort  should  be 
made  to  prevent  and  not  to  hasten  abortion. 

These  fluids,  although  having  no  relation  in  their  seat  to  the  liquor 
amnii,  have,  however,  been  called  the  false  water?,  so  as  to  distinguish  them 
from  those  which  escape  after  the  membranes  are  ruptured  in  labor. 

Various  opinions  have  been  advanced  as  to  the  nature  and  seat  of  these 
false  waters;  thus,  certain  accoucheurs  have  supposed  that  they  were  con- 
tained between  the  chorion  and  the  amnion,  and  that  their  escape  is  due  to 
a  laceration  of  the  chorion ;  others,  that  they  are  owing  to  the  rupture  of 
an  livdatid,  lodged  either  in  the  cavity  or  the  neck  of  the  uterus  (Koehmer, 
Roederer).  Again,  Baudelocque  was  of  the  opinion  that  it  resulted  from 
the  transudation  of  the  liquor  amnii  through  the  membranes.  Some  others 
explain  it  by  invoking  an  ©edematous  condition  and  an  infiltration  of  the 
uterine  cellular  tissue.  It  is  an  easy  matter  to  refute  all  these  opinions  by 
recalling  the  fact  of  the  frequency  and  abundance  of  the  discharges',  which 
often  come  away  in  large  quantities.  Mauriceau,  Camper,  and  Capuron 
supposed  that  these  waters  proceed  from  the  interior  of  the  amnion;  for,  in 
certain  cases,  they  say,  the  membranes  may  yield  at  a  point  quite  distant 
from  the  neck,  and  the  superabundance  of  this  fluid  will  then  gradually 
drain  away,  though  still  an  abortion  may  not  occur. 

This  explanation  is  not  applicable  to  the  greater  number  of  cases  of 
hydrorrhea,  for  observation  does  not  show  that  when  water  came  away 
several  times  during  pregnancy  the  amount  lost  during  labor  was  less  than 
usual:  beside  which,  careful  examinations  of  the  membranes  after  delivery 
have  very  rarely  detected  traces  of  old  rupture.  Some  well  observed  cases, 
however,  prove  that  Mauriceau's  opinion  may  be  exceptionally  true.  (See 
page  543.) 

It  is  much  more  probabk  that  the  fluid  which  thus  escapes  in  the  course 
of  gestation,  sometimes  a  few  days  only  before  term,  had  accumulated  be- 
tween the  internal  uterine  surface  and  some  portion  of  the  membranes 
(variable  in  extent)  that  were  detached.  This  is  the  view  advocated  by 
Na:gele,  and  it  has  been  lately  reproduced  by  one  of  his  pupils  in  a  thesis 
sustained  at  Heidelberg,  from  which  I  have  derived  most  of  these  details. 
That  is  to  say,  the  fluid  secreted  by  the  internal  surface  of  the  organ  gradu- 
ally detaches  the  membranes,  thereby  forming  a  pouch  for  itself  until  its 
constantly-increasing  quantity  succeeds  in  separating  them  as  far  as  the 
neck,  when  an  irruption  of  the  liquid  takes  place. 


DISEASES     OF     THE     OVUM.  517 

This  theory  was  confirmed  by  the  autopsy  of  a  pregnant  woman  affected 
with  hydrorrhcea.  Dr.  Duclos,  of  Toulouse,  who  relates  the  case,  found  the 
membranes  partly  detached  and  from  that  point  the  fluid  escaped.  Else- 
where the  membranes  were  raised  by  an  accumulation  of  fluid  between 
them  and  the  uterine  wall,  being  thus  ready,  so  to  speak,  to  give  rise  to  a 
fresh  attack  of  hydrorrhcea  whenever  the  detachment  should  extend  to  the 
cervix. 

Now,  if  we  admit  with  Professor  Burdach,  that  an  exhalation  takes 
place  from  the  internal  surface  of  the  uterus,  which,  by  transuding  through 
the  membranes,  reaches  the  amniotic  cavity,  and  thereby  contributes  to  the 
nutrition  of  the  foetus  during  the  greater  part  of  the  intra-uterine  life,  it 
would  be  easy  to  explain  this  abnormal  accumulation  of  fluids,  either  by  an 
excess  of  secretion  or  an  arrest  of  transudation.  It  may  also  be  explained 
by  supposing  that  the  secretion  continues  beyond  the  ordinary  term,  and 
the  liquid  is  obliged  to  create  a  cavity  or  a  kind  of  reservoir  for  itself  by 
detaching  the  membranes  to  a  certain  extent. 

Generally  speaking,  this  is  not  a  serious  affection;  nevertheless,  if  fre- 
quently repeated,  it  might  bring  on  premature  contractions. 

The  treatment  is  very  simple.  The  patient  must  maintain  the  most  per- 
fect rest,  avoiding  all  moral  and  physical  excitement  during  the  flow,  and 
for  seven  or  eight  days  after  it  has  ceased.  Should  it  be  followed  by  slight 
contractions,  enemata,  containing  laudanum,  would  arrest  them;  and  if  the 
discharge  is  accompanied  by  any  evidences  of  general  or  local  plethora,  these 
symptoms  must  be  promptly  met  by  the  appropriate  measures. 

[I  3.  Dropsy  of  the  Villi  of  the  Chorion.     Hydatiform  Mole. 

The  villi  of  the  chorion  sometimes  become  distended  by  fluid  which  collects 
within  them,  causing  them  to  swell  and  assume  the  form  of  rounded  vesicles,  com- 
parable to  gooseberries  or  grapes,  and  having,  consequently,  some  resemblance  to 
hydatid  vesicles.  On  account  of  this  analogy,  they  were,  for  a  long  time,  supposed 
to  be  true  hydatids.  M.  Velpeau  was  the  first  to  discover  that  the  hydatiform  mole 
has  its  origin  in  the  chorion,  and  the  microscopic  examinations  of  Prof.  Robin  ex- 
hibited still  more  clearly  the  true  nature  of  the  disease  by  showing  that  the  en- 
velope of  the  hydatiform  vesicles  have  all  the  anatomical  characteristics  of  the 
walls  of  the  villi  of  the  chorion.  It  is  now  regarded  as  certain  that  the  disease 
known  as  hydatiform  mole  is  nothing  but  a  dropsical  condition  of  the  villi  of  the 
chorion. 

Though  the  affection  is  a  rare  one,  we  have  a  good  account  of  it  in  Dr.  Cayla's 
thesis,  which  we  have  found  very  useful  in  the  preparation  of  this  article. 

If  an  ovum,  presenting  the  alteration  in  question,  be  examined,  the  villi  are 
seen,  as  usual,  detached  from  the  surface  of  the  chorion.  In  some  cases,  the 
pedicles  will  have  undergone  no  change  in  size,  whilst  at  others  they  will  be 
dhghtly  dilated.  The  dilatations,  or  vesicles,  begin  to  appear  where  the  ramifica- 
tion commences,  the  branches  of  the  villi  being  found  swollen  at  intervals.  The 
dilatations  vary  in  size  from  that  of  a  walnut  to  that  of  a  filbert,  and  so  down  until 
they  become  almost  invisible  to  the  naked  eye.  A  whole  villus  is  often  almost 
completely  metamorphosed  into  a  bunch  of  vesicles  almost  as  large  as  gooseberries. 

Upon  the  larger  of  these,  s !ler  ours  are  often  inserted,  and  generally  by  a  very 

fine  pedicle,  a  portion  of  the  undilated  branch  of  the  chorion.  The  pedicle  varies 
from  -039  to  -078  inches  in  length.  Sometimes  it  is  extremely  fine,  but  may  reach  a 
diametor  of  039  inches;  in  which  case  it  allows  the  fluid  to  flow  through  it  from 


548  PATHOLOGY    OF    PREGNANCY. 

one  vesicle  into  the  <  ther.  More  frequently,  it  is  obliterated  through  a  greatei  or 
less  extent  of  its  course.  All  the  vesicles  of  the  same  group  are,  therefore,  con- 
nected by  pedicles,  forming  groups  of  the  strangest  appearance,  but,  nevertheless, 
recalling  that  of  the  villi  in  the  normal  condition. 

It  is  generally  easy  enough  to  separate  the  vesicles  from  each  other,  and  to  trace 
tin-  pedicles  down  to  the  chorion  ;  sometimes,  however,  they  are  inextricable. 

The  fluid  contained  in  the  vesicles  is  usually  colorless,  transparent,  liquid  as 
water,  and  containing  albumen  in  solution.  Occasionally,  the  contents  are  of  a 
reddish  color. 

Tli is  dropsical  condition  may  affect  either  the  villi  of  the  chorion,  properly  so 
nailed,  or  those  of  the  placenta,  and  in  both  cases  the  life  of  the  foetus  is  nearly 
always  compromised.  The  dominant  fact  in  the  affection  is,  after  all,  the  arrange- 
ment of  the  umbilical  vessels.  Should  all  the  villi  become  dropsical,  the  death  of 
the  foetus  would  necessarily  ensue,  and,  occurring  at  a  period  very  near  that  of 
conception,  it  might  undergo  solution  in  the  amniotic  fluid,  and  thus  disappear. 

Should  the  alteration  of  the  villi  be  more  recent  or  less  complete,  we  should  have 
an  embryonic  mole,  in  which  the  body  of  the  foetus  would  present  various  grades 
of  development.  Sometimes  even,  though  rarely,  when  the  alteration  affects  a 
small  number  of  villi,  the  foetus  may  be  fully  developed.  Finally,  a  case  of  M. 
Brachet's  proves  that  a  few  hydatiform  vesicles  occurring  on  the  placenta  do  not 
prevent  the  birth,  at  term,  of  a  healthy  child  of  the  usual  size.  It  is  certain  that 
in  twin  pregnancies  an  alteration  of  one  ovum  may  affect  the  other  injuriously  ; 
still,  some  cases,  reported  in  the  Dictionary,  in  thirty  volumes,  show  that  one  ovum 
may  be  transformed  into  a  hydatiform  mole,  whilst  the  other  foetus  undergoes 
regular  development,  and  is  born  at  term. 

By  what  symptoms  may  dropsy  of  the  villi  of  the  chorion  be  suspected  or  dis- 
covered ?  If  the  alteration  be  slight,  none  of  the  usual  signs  of  pregnancy  will  be 
wanting,  and  then  a  diagnosis  will  be  almost  impossible.  If,  on  the  contrary,  the 
change  is  so  great  as  to  completely  alter  the  ovum,  the  affection  may  be  suspected 
and  occasionally  discovered.  All  writers  admit  that  attacks  of  hemorrhage  are 
common  in  such  cases,  and  they  almost  always  coincide  with  an  unusual  develop- 
ment of  the  uterus,  whose  size  is  no  longer  in  conformity  with  the  presumed  period 
of  gestation.  These  two  symptoms  are  found  conjoined  in  a  case  of  M.  Depaul's, 
already  published  by  M.  Cayla.  The  most  important  sign,  however,  is  a  too  rapid 
increase  in  the  size  of  the  uterus,  and  by  it  was  a  positive  diagnosis  made  in  the 
following  case,  which  we  owe  to  the  kindness  of  M.  Pajot,  from  whom  we  received 
it.  The  account  will  be  read  with  interest:  "I  saw  a  case  ()f  so-called  uterine 
hydatids  in  connection  with  Dr.  Gocherand  (of  Ivry),  and  although  it  was  the  third 
one  of  the  kind  which  has  fallen  under  my  notice,  the  circumstances  attending  it 
were  very  different  from  my  own  two  first  cases,  and  afforded  the  opportunity  of 
studying  a  much  greater  alteration  of  the.villi  of  the  chorion." 

The  patient  was  a  young  woman  who  had  given  birth  to  a  child  about  a  year 
previously,  and  who  now  supposed  herself  to  be  about  three  months  pregnant.  On 
making  an  examination  I  was  astonished  to  find  the  uterus  as  large  as  at  the  eighth 
month  of  gestation.  A  very  marked  sense  of  fluctuation  made  me  at  first  suppose; 
that  there  might  be  a  collection  of  fluid  or  a  rapidly  developed  cyst  of  the  ovary. 
However,  I  soon  became  satisfied  that  there  was  an  accumulation  of  fluid  in  the 
rjavity  of  the  uterus  itself. 

By  vaginal  examination  I  found  that  the  lower  segment  of  the  uterus  was 
considerably  developed.  The  neck  was  as  soft  as  at  the  eighth  month  of  gestation, 
and  presented  the  indications  of  a  previous  labor.  The  finger  could  be  inserted  as 
far  as  to  the  internal  orifice,  which  was  closed  hermetically.  By  passing  the  finger 
around  the  cul-de-sac,  the  left  hand  at  the  same  time  being  applied  upon  the  fundus 
if  the   uterus,  the  sense  of  fluctuation  already  perceived  so  clearly  by  palpation, 


DISEASES    OF    THE     OVUM.  549 

was  again  evident.  There  was  no  solidity  at  any  point  of  the  abd)men.  The 
patient's  general  health  was  bad  ;  she  had  a  dry,  hot  skin,  and  pulse  at  120. 

It  was  the  only  one  of  the  three  cases  in  which  a  diagnosis  could  be  established. 

I  advised  the  insert  on  of  a  gum-ehistic  catheter  through  the  internal  orifice,  and 
the  administration  of  ergot.  The  advice  was  followed  the  next  day,  and  the  patient 
expelled,  together  with  a  large  quantity  of  fluid,  a  multitude  of  hydatiform  vesicles, 
either  in  a  detached  state  or  in  clusters  of  five  or  six  together.  The  entire  collec- 
tion would  have  filled  a  man's  hat.  The  vesicles  were  taken  to  Paul  Dubois,  who 
showed  them  to  his  class,  and  made  them  the  subject  of  a  lecture. 

The  evacuation  was  followed  by  no  improvement  in  the  general  symptoms;  the 
patient  continued  to  lose  strength,  and  died  a  few  days  after  the  operation.  Unfor- 
tunately, an  autopsy  could  not  be  obtained.     (Pajot.) 

Although  the  uterus,  in  these  cases,  is  generally  too  large  for  the  stage  of  the 
pregnancy,  it  is  sometimes  in  the  opposite  condition.  (Thesis  of  Dr.  Louvet- 
Lamarre.) 

The  pregnancy  usually  terminates  earlier  than  in  normal  cases,  expulsion  of  the 
ovum  generally  taking  place  before  the  sixth  month,  and  in  the  usual  manner;  all 
the  symptoms  which  precede,  attend,  or  follow  it  resembling  precisely  those  of 
abortion,  though  the  accompanying  hemorrhage  is  commonly  profuse. 

The  formation  of  an  hydatiform  mole  rarely  appears  to  have  any  effect  upon  the 
general  health  of  the  patient,  or  upon  subsequent  pregnancies.  Madame  Boivin, 
however,  mentions  some  cases  of  women  who  wel'e  so  unfortunate  as  to  suffer 
repeatedly  from  the  affection. 

ARTICLE    II. 

LESIONS   OF   THE    VILLI   OF   THE   PLACENTA. 

Although  changes  in  the  structure  of  the  placenta  are  quite  common,  our  knowl- 
edge of  them  is  as  yet  so  limited,  that  in  a  work  like  the  present  we  shall  be  able 
to  notice  only  the  most  important  of  them. 

A  clear  statement  of  what  may  be  said  of  the  pathology  of  the  placenta,  makes  it 
necessary  to  revert  to  some  details  respecting  the  chorion  and  its  villi.  The  two 
latter  are  composed  of  the  same  substance,  that  is  to  say,  of  a  membrane  formed  of 
polyhedral  cells,  which  are  easily  distinguished  up  to  the  sixth  week.  At  a  later 
period  their  nucleolus  disappears,  the  nucleus  loses  its  transparency,  and  the  cell 
itself  becomes  filled  with  granules.  In  this  way  the  chorion  soon  assumes  the 
appearance  of  a  continuous  membrane,  which  is  more  or  less  granular  and  sprinkled 
with  nuclei. 

In  its  beginning  the  chorion  has  the  form  of  a  regular  hollow  sphere,  with  smooth 
outlines;  soon,  however,  its  surface  becomes  covered  with  multitudinous  prolonga- 
tions, to  which  the  term  villi  has  been  applied.  Almost  all  these  prolongations 
are  traversed  by  a  canal,  which  terminates  in  a  cul-de-sac  at  the  free  extremity  of 
the  villus,  but  opens  freely  at  the  internal  surface  of  the  chorion.  This  internal 
surface  is,  therefore,  covered  with  minute  perforations,  each  communicating  with 
the  canal  of  its  respective  villus.  AVhen  the  allantoic!  is  formed,  it  becomes  applied 
against  the  internal  surface  of  the  chorion,  and  quickly  sends  vascular  prolongations 
into  most  of  the  villi.  Some  of  these  villi  then  continue  to  grow,  so  as  to  form  the 
placenta;  the  rest  become  atrophied  in  a  way  which  has  been  well  described  by 
Robin  (Archives  Generates  de  Me'decine,  1848,  et  Gazette  Medicate,  1854),  and  which 
affords  the  key  to  some  of  the  lesions  of  the  placenta.  Prof.  Robin's  investigations 
may  be  recapitulated  ati  fi  Hows  :  — 

1.  During  the  formation  of  the  villi  the  development  of  some  of  them  is  arrested, 
so  that   they   contain   no  central   canal,  and   consequently   can   have  no   participation 


j>50  PATHOLOGY  OF  PREGNANCY 

in  the  allantoid  circulation.     They  appear  as  solid  cyli   ders,  having  imledded  in 
their  tissue  an  abundance  of  grayish  granules. 

2.  Although  most  of  the  villi  are  provided  each  with  .1  canal,  some  of  them  fail 
to  receive  a  prolongation  of  the  allantoid ;  these,  consequently,  remain  tubular,  and 
are  distinguished  by  the  abundance  of  fatty  molecular  granules,  with  which  then 
parietes  are  sprinkled. 

3.  Although  nearly  all  the  villi  become  vascular  at  a  certain  stage  in  the  devel- 
opment of  the  ovum,  most  of  them  have  become  atrophied  by  the  time  the  placenta 
is  distinct.  In  following  up  this  process  of  atrophy,  the  allantoid  vessels  traversing 
the  villus  are  first  observed  to  disappear,  and  the  canal  is  quickly  obliterated, 
beinc  filled  with  a  tissue  resembling  the  reticulated  magma.  The  walls  of  the 
villus  itself  bee  >me  charged  with  fat  in  the  shape  of  fatty  granules  and  real  oil- 
drops,  sometimes  scattered  and  sometimes  in  collections  of  various  forms. 

4.  The  placental  villi  occasionally  present  the  same  indications  of  atrophy  as  are 
constant  in  the  other  villi  in  the  chorion;  in  other  words,  the  placental  villi  may 
undergo  atrophy,  cease  to  be  vascular,  and  exhibit  an  abundant  fatty  deposit  in 
their  walls. 

We  shall  soon  explain  the  mode  by  which  the  normal  atrophy  of  the  villi  of  the 
chorion  gives  rise  to  important  lesions  when  it  happens  to  extend  to  those  villi 
which  go  to  form  the  placenta. 

FIBROUS   OBLITERATION   OF   THE   PLACENTAL    VILLI    WITH    OR   WITHOUT 
FATTY    DEGENERATION. 

The  lesion  in  question  has  been  described  as  induration  of  the  placenta,  encepha- 
loid,  scirrhous,  cancerous,  tuberculous,  and  fatty  degeneration:  still  oftener  has  it 
been  mistaken  for  a  fibrinous  deposit,  the  remains  of  a  placental  apoplexy.  (See 
Placental  Apoplexy.) 

The  degeneration  appears  in  the  form  of  grayish  or  whitish  masses,  which  are 
always  less  red  and  moist  than  the  rest  of  the  placenta,  and  of  a  tissue  which  is 
hard,  compart,  friable,  and  but  slightly  stringy.  This  appearance  has  caused  them 
to  be  mistaken  for  concrete  pus,  masses  of  crude  tubercle  or  scirrhous  formations. 
When,  however,  they  are  examined  under  the  microscope,  it  is  soon  seen  that 
all  the  parts  of  the  tissue  thus  altered  are  composed  of  obliterated  villi  of  the 
chorion  with  their  tissue  charged  with  fatty  granules.  All  the  ramifications, 
however,  are  not  thus  supplied  with  fat,  since  in  the  parts  apparently  the  most 
diseased  and  distinguished  by  their  whitish  color,  the  villi  contain  no  trace  of  fat 
granules,  or  have  them  only  at  long  intervals.  In  a  word,  the  lesion  which  we  are 
describing  is  characterized  by  obliteration  of  the  placental  villi,  precisely  similar 
to  the  atrophy  which  invades  the  villi  of  the  chorion  after  the  formation  of  the 
placenta,  and  which  we  have  described  above. 

This  alteration  is  more  especially  met  with  at  the  circumference  of  the  placenta, 
the  cotyledons  in  that  situation  being  the  ones  chiefly  affected.  It  may  always  be 
found  in  the  cotyledons  of  the  periphery,  or,  at  least,  in  a  small  portion  of  some  of 
them:  in  this  cum',  however,  the  affected  ramifications  of  the  chorion  are  lost,  as  it 
were,  in  the  midst  of  those  which  remain  pervious,  and  in  this  degree  the  disease 
is  of  no  interest  to  the  clinical  observer. 

In  certain  placentas,  however,  there  will  be  one  or  several  portions  of  cotyledons, 
or  even  one  or  several  entire  cotyledons,  which  have  undergone  fibro-fatty  degen- 
eration ;  and  sometimes  even  the  greater  part  of  the  placenta  is  thus  transformed 
into  a  morbid  tissue  which  is  impervious  to  blood. 

A  placenta  examined  by  MM.  Laboulbene  and  Iliffelsheim  had  six  of  its  cotyle- 
dons entirely  obliterated,  beside  whicb  there  were  discovered  eleven  other  small, 
yellowish  masses,  presenting  the  same  external  characters  and  structure  as  the 
diseased  cotyledons.     The  altered  cotyledons  are  sometimes  scattered  through   the 


DISEASES   OF   THE   OVUM.  55] 

placental  mass,  at  other  times  they  touch  by  their  edges,  but  are  ilways  definitely 
separated  by  deep  furrows.  The  change  is  generally  more  evident  upon  the  uterinfl 
surface  of  the  cotyledons  than  upon  the  side  of  the  chorion,  for,  there  the  tissue 
resumes  gradually  its  softness,  humidity,  ami  reddish  hue. 

"  If  the  placenta  be  emptied  of  blood,"  says  M.  Robin,  from  -whom  we  borrow 
almost  the  whole  of  this  article,  "  the  diseased  cotyledons  will  project  more  than 
the  healthy  ones ;  but  if  the  placenta  be  injected,  the  former  will  be  depressed  in 
comparison  with  the  latter.  This  result  is  due  to  the  fact  that  the  ramifications 
which  remained  vascular  in  the  emptied  placenta,  subside  in  consequence  of  the 
discharge  of  their  blood;  but  as  the  obliterated  ones  do  not  collapse,  their  bulk 
remains  greater  than  that  of  the  others.  When,  on  the  contrary,  the  healthy  ai  d 
vascular  cotyledons  are  distended  by  injection,  they  form  a  larger  mass  than  those 
whose  subdivisions  are  obliterated,  and  appear  in  relief  beside  them." 

The  alterations  just  described  are  independent  of  hemorrhage  or  placental  apo- 
plexy. Whenever  the  two  affections  have  been  confounded,  the  observers  were, 
doubtless,  deceived  by  their  coincidence.  It  is,  indeed,  by  no  means  rare  to  find 
an  apoplectic  space  in  the  centre  of  the  diseased  cotyledons,  large  enough  to  contain 
a  pea,  a  bean,  or  only  a  millet-seed,  and  the  fibro-fatty  degeneration  of  the  villi 
has  often  been  mistaken  for  a  bleached  clot.  This  confusion  is  now  impossible, 
thanks  to  the  microscope,  which  discovers  in  the  mass  of  diseased  cotyledons  not  a 
collection  of  fibrin,  but  a  network  of  atrophied  villi  of  the  chorion. 

A  single  argument  remains  in  favor  of  the  view  which  attributes  them  to  apo- 
plexy, to  wit,  that  the  hemorrhage  which  takes  place  causes  the  obliteration  of  the 
cotyledons.  To  us  it  seems  impossible  thus  to  make  the  obliteration  subordinate 
to  the  apoplexy,  and  M.  Robin's  researches  tend  to  prove  that  the  fibro-fatty  altera- 
tion may  become  a  cause  of  hemorrhage  as  regards  the  neighboring  villi  which 
continue  pervious.  Moreover,  as  a  matter  of  fact,  placental  apoplexy  is  met  with, 
without  obliteration  of  the  cotyledons,  and  it  is  very  often  impossible  to  discover  a 
trace  of  apoplexy  in  cotyledons  which  are  completely  obliterated.  The  two  lesions 
are,  therefore,  mostly  independent  of  each  other. 

Obliteration  of  the  placental  cotyledons  is  without  importance  as  regards  the 
mother,  but,  as  will  be  readily  understood,  may  be  highly  injurious  to  the  foetus. 
It  is,  indeed,  proved  that  an  almost  constant  relation  exists  between  the  weight  of 
the  foetus  and  that  of  the  placenta.  Now  in  the  case  before  us,  any  obliteration  of 
the  villi  cuts  off  by  so  much  the  active  portion  of  the  placenta  ;  if  but  a  few  villi  be 
obliterated,  the  child  experiences  no  bad  effect  from  it,  but  if  several  cotyledons  bo 
altered,  its  development  will  be  imperfect,  and  should  half  of  the  organ  be  invaded, 
its  life  will  incur  the  greatest  danger.  In  a  still  more  advanced  stage,  its  death  is 
almost  certain. 

All  our  knowledge  of  the  fibro-fatty  degeneration  of  the  placenta  is,  so  to  speak, 
condensed  into  the  anatomo-pathological  statement  just  given,  and  we  are  obliged 
to  confess,  as  does  Dr.  Millet,  whose  excellent  work  may  be  consulted  with  advan- 
tage, that  there  is  nothing  to  give  us  light  upon  the  etiology  of  this  lesion,  no  sign 
which  enables  us  to  fix  its  symptomatology  upon  a  certain  foundation.  Sometimes, 
however,  there  have  been  evidences  of  uterine  congestion  in  eases  in  which  the 
patients  had  complained  of  weight  or  pain  in  the  loins.  These  symptoms  then 
resemble  those  observed  in  cases  of  placental  apoplexy,  and,  we  would  observe,  are 
really  so  vague  or  even  insignificant  that  it  would  seem  to  us  almost  impossible  to 
diagnose  the  fibro-fatty  degeneration  in  a  case  of  first  pregnancy.  As,  however,  the 
affection  is  liable  to  recur  and  sometimes  adheres  tenaciously  to  tin'  same  woman 
in  all  her  pregnancies,  the  accoucheur  may  take  warning  and  let  the  least  trouble 
occurring  either  to  the  mother  or  foetus  during  gestation  have  its  weight  in  his 
estimate  of  the  situation.  M.  P.  Dubois  says,  in  reference  to  these  matters,  that, 
if  a  sense  of  dull  pain  and  fulness  is  connected  with  a  slight  diminution  of  the 
motions  of  the  foetus,  there  is  reason  to  fear  that  it  is  in  serious  danger. 


552  PATHOLOGY    OF    PREGNANCY. 

It  is  possible,  then,  to  suspect  or  even  to  foresee  the  fibre-fatty  degeneration  of  the 
placenta;  but  how  shall  it  be  prevented?  What  course  shall  be  pursued  if  the 
woman  becomes  pregnant  again? 

M.  Dubois'  advice  to  his  pupils,  under  these  circumstances,  is  thus  briefly  stated 
by  Dr.  .Miller  :  Ad  vise  the  patient  to  avoid  all  kinds  of  fatigue;  insist  upon  her  lying 
down,  and  prescribe  a  light  diet  fur  the  purpose  of  moderating  the  circulation.  At 
the  same  time  practise  a  revulsive  bleeding  to  the  extent  of  from  one  to  two  ounces. 
followed  the  day  after  by  a  similar  one.  In  connection  with  this  apparently 
reducing  treatment,  M.  Dubois,  without  fear  of  being  taxed  with  inconsistency,  adds 
the  use  of  iron,  inasmuch  as  it  has  appeared  to  him  that  women  are  predisposed  to 
the  affection  by  a  certain  degree  of  impoverishment  of  the  blood.  The  iron  would, 
at  any  rate,  seem  in  several  instances  to  have  benefited  the  patients. 

AETICLE   III. 

EFFUSION  OF  BLOOD  IN  THE  PLACENTA. 

Utero-placental  hemorrhage  will  be  studied  in  all  its  connections  when  treating 
of  abortion  or  the  hemorrhages  accompanying  delivery  (see  Abortion,  and  Dystocia) ; 
we  are,  however,  to  speak  in  this  place  of  certain  effusions  of  blood  in  the  substance 
of  the  placenta  which  present  peculiarities  deserving  of  special  attention.  These 
effusions  differ  considerably  both  in  situation  and  form,  the  variety  being  due,  for 
the  most  part,  to  the  more  or  less  advanced  stage  of  the  development  of  the  placenta. 
Thus,  if  the  blood  occupy  circumscribed  cavities  formed  in  the  tissue  of  the  organ, 
it  takes  the  name  of  placental  apoplexy  given  to  it  by  M.  Cruveilhier,  and  will  be 
described  in  the  next  paragraph.  Up  to  the  third  month,  however,  not  only  may 
the  blood  be  effused  into  the  placenta  itself,  but  may  even  extend  beyond  its  limits 
and  spread  over  the  entire  external  surface  of  the  chorion.  This  last  variety  will 
be  the  first  to  engage  our  attention. 

As  utero-placental  hemorrhage  has  been  so  well  treated  of  by  M.  Jacquemier,  we 
can  do  no  better  than  borrow  several  passages  of  his  description.  Up  to  the  third 
month,  as  stated,  the  blood  effused  into  the  placenta  has  a  great  tendency  to  spread 
itself  over  the  surface  of  the  chorion  ;  in  fact,  it  could  hardly  be  otherwise,  for  at 
the  outset  the  placental  villi  are  not  yet  connected  by  the  amorphous  tissue  which 
at  a  later  period  forms  of  them  compact  lobes,  and  the  circumference  of  the  pla- 
centa is  not  yet  well  defined,  there  being  no  distinct  limit  between  the  villi  of  the 
placenta  and  those  of  the  chorion,  which  latter  are  destined  soon  to  disappear.  The 
entire  surface  of  the  chorion  is,  in  fact,  at  this  time  covered  with  prolongations  which 
separate  to  a  certain  extent  its  external  surface  from  that  of  the  decidua  reflexa 
until  both  membranes  are  brought  into  contact  through  the  atrophy  of  the  villi. 
Should  a  rupture  now  occur  of  some  of  the  utero-placental  vessels  either  in  process 
of  development  or  but  recently  perfected,  the  blood  therefrom  would  soon  reach  all 
the  vascular  tufts  of  the  placenta  ami  villi  of  the  chorion  by  spreading  itself  in  a 
layer  between  the  ovular  decidua  and  the  chorion.  The  aborted  ovum  under  these 
circumstances  often  has  a  fleshy  appearance,  its  surface  being  more  or  less  bluish 
or  Idackish,  whilst  its  walls  form  an  envelope  of  variable  solidity  and  thickness. 
If  it  be  entire,  a  careful  examination  will  often  detect  on  the  external  surface  of 
the  placenta  minute  ruptures  opening  into  cavities  and  closed  or  not  by  coagulated 
blood.  Frequently,  also,  there  is  no  rupture,  although  the  placenta  may  contain 
deep-seated,  circumscribed  cavities  or  extensive  diffused  infiltrations.  If  the  layers 
of  the  decidua  be  Btripped  from  the  ovum,  the  entire  surface  of  the  chorion,  the 
portion  occupied  by  the  placenta  included,  will  be  found  covered  by  coagulated 
blood  which  is  firmly  held  by  the  vascular  ramifications  of  the  placenta  and  the 
villi  of  the  chorion  imprisoned  in  its  substance.  Both  chorion  and  amnion  are 
intact,  the  amnii  tic  fluid  having  a  slightly  red  color  by  imbibition.     If  the  embryo 


DISEASES   OF   THE   OVUM.  553 

be  very  young,  it  may  sometimes  be  found  to  be  entirely  dissolved,  the  Mily  trace 
left  of  its  existence  being  a  very  small  bit  of  the  cord  still  attached  to  the  placenta 
by  a  few  fragments  of  a  very  soft  tissue.  At  other  times  the  amniotic  liuid  may 
merely  seem  to  be  a  little  thicker  than  usual,  resembling  in  this  respect  a  mucilage 
of  gum.  Should  the  structure  of  the  embryo  be  firmer,  it  will  be  found  in  its  normal 
condition,  only  more  or  less  withered  and  macerated  according  to  whether  the  date  of 
its  death  be  more  or  less  remote.  The  blood  covering  the  entire  surface  of  the  chorion 
sometimes  forms  a  firm  and  hard  coagulum,  which,  occasionally,  in  some  parts  has 
lost  its  color  and  resembles  the  huffy  coat  of  blood  from  venesection  ;  at  other  times 
it  is  soft  and  presents  the  appearance  of  a  black-,  thick,  and  granular  fluid. 

The  amount  of  blood  effused  varies  greatly,  and  the  layer  formed  by  it  may  be 
only  from  ,068  to  -136  inches,  or  from  '78  to  *.1'17  inches  iu  thickness.  In  the  latter 
case,  the  euds  of  the  villi  will  have  lost  their  relation  with  the  reflected  and  inter- 
utero-placental  deciduas,  thus  producing  an  unnatural  widening  of  the  interstice 
which,  in  the  normal  state,  is  very  small.  The  layer  of  blood  is  not  of  equal 
thickness  at  all  points;  in  some  places  it  collects  in  larger  quantity,  and  that  most 
generally  where  the  placenta  would  have  been  formed.  Ova  thus  affected  have, 
sometimes,  another  appearance  ;  thus,  if  during  their  expulsion  the  decidua  has 
been  removed,  as  often  happens,  they  look  like  a  clot  of  blood,  but  dissection  and 
washing  soon  discover  in  their  tissue  the  vascular  ramifications  of  the  placenta  and 
villi  of  the  chorion,  showing  that  the  seat  of  the  effusion  is  the  same  as  in  the 
preceding  case,  and  that  they  are  not  merely  ova  wrapped  in  their  deciduas  and 
enclosed  in  a  clot  of  blood. 

At  a  rather  later  period  of  gestation,  say  the  third  or  fourth  month,  the  effusion 
spreads  much  less  over  the  surface  of  the  chorion  and  shows  a  tendency  to  be  con- 
fined to  the  placenta  ;  still,  it  will  sometimes  extend  beyond  the  edges  of  the  latter 
in  the  form  of  streaks,  projecting  iu  various  directions  to  a  greater  or  less  distance. 
The  limitation  of  the  effusion  is  due  to  the  approximation  and  somewhat  firm 
adherence  between  the  chorion  and  the  decidua  reflexa,  due  to  the  atrophy  of  the 
villi  of  the  chorion,  so  that  a  space  no  longer  exists  between  the  two  membranes 
except  for  a  variable  distance  near  the  border  of  the  placenta.  Even  should  we 
suppose  that  these  effusions  exert  a  considerable  force,  it  is  not  generally  sufficient 
to  rupture  the  membranous  envelopes  which  restrain  them.  Still  it  is  not  so  very 
rare  for  the  decidua  reflexa  to  give  way  and  allow  the  blood  to  pass  into  the  cavity 
of  the  decidua  and  even  reach  the  internal  surface  of  the  uterus.  As  an  excep- 
tional occurrence  it  is  sometimes  found  to  have  ruptured  the  chorion  and  amnion, 
^8  in  the  cases  observed  by  M.  Gendrin,  who  found  blood  effused  between  the 
ihorion  and  amnion,  and  even  in  the  cavity  of  the  latter,  where  it  enveloped  the 
embryo  completely.  Within  the  periods  of  foetal  life  above  mentioned,  there  can 
be  no  doubt  that  the  effused  blood  proceeds  from  a  rupture  of  the  utero-placental 
vessels,  even  though  it  be  impossible  to  detect  any  lesion  upon  the  external  surface 
>f  the  placenta.  It  is  impossible  to  suppose  that  the  blood  comes  from  the  umbil- 
ical vessels,  for  we  have  seen  that  in  some  cases  the  embryo  is  so  slightly  developed 
as  soon  to  be  dissolved,  whilst  in  others  the  amount  of  blood  effused  generally  far 
exceeds  the  entire  bulk  of  the  embryo.  If  the  umbilical  vessels  are  ever  ruptured, 
they  could  only  be  so  consecutively  to  rupture  of  the  utero-placental  vessels,  in 
which  case  the  foetal  and  maternal  blood  would  mingle  together. 

An  occurrence  of  this  kind  happening  to  the  extent  just  imagined,  would,  gener- 
ally, be  fatal  to  the  foetus,  though  the  ovum  would  nut  be  expelled  until  later.  Aa 
the  effused  blood  is  not  in  contact,  with  the  walls  of  the  uterus,  it  does  not  stimu- 
late tin;  organ  immediately  to  contraction,  and  it  very  often  happens  thai  when 
abortion  takes  place,  tin;  blood  is  found  to  have  already  begun  to  lose  its  color,  as 
also  to  present  Other  changes  indicating  thai  the  hemorrhage  must  have  taken 
place  some  time  previously.  Should  the  effusion  be  moderate]  it  would  nut  seem  im- 
possible I'ui-  gestation  to  continue.     (Jacquemier.) 


554  PATHOLOGY    OF    PREGNANCY. 


PLACENTAL   APOPLEXY. 


Mr.  Jacquemier's  book  again  guides  us  in  describing  placental  apoplexy.  From 
the  middle  of  intra-uterine  life  the  placenta  continues  to  be  quite  frequently  the 
seat  of  effusions  of  blood,  which  effusions  are  peculiar  from  the  fact  that  they  no 
Longer  extend  beyond  its  edges  between  the  now  firmly  united  chorion  and  decid'ia. 
Instead  of  being  diffused  and  occupying  the  greater  part  or  even  the  whole  of  the 
placenta,  these  effusions  are  more  fully  circumscribed  and  confined  to  the  lobes  in 
which  the  ruptured  vessels  are  situated,  although  they  always  show  a  strong  ten- 
dency to  extend  toward  the  foetal  surface  of  the  placenta.  They  also  present 
varieties  which  may  be  described  under  three  principal  heads. 

In  the  first  variety  there  is  no  cavity,  properly  so  called,  produced,  but  the  blood 
infiltrates  the  tissues  of  one  or  more  lobes  of  the  placenta,  apparently  diminishing 
its  density.  In  some  places  it  accumulates  sufficiently  to  form  little  vacuoles 
filled  with  a  very  dark-colored  fluid  which  in  some  cases  has  the  appearance  of  a 
very  thin  jelly.     (Jacquemier.) 

In  the  second  variety  the  effused  blood  forms  a  very  irregular  cavity,  having 
prolongations  in  various  directions,  and  the  parts  adjacent  are  infiltrated  and 
stained  of  a  reddish  hue  for  a  very  considerable  distance.  The  foci  are  usually 
quite  large  and  mostly  communicate  with  the  external  surface  of  the  placenta 
through  a  rupture  of  greater  or  less  size,  with  detachment  of  the  parts  correspond- 
ing; they  are  irregular  in  form  and  more  liable  to  be  found  near  the  edge  of  the 
placenta  in  proximity  to  the  coronary  vein,  which  is  sometimes  ruptured,  and 
communicating  with  the  cavity.  When  the  effusion  takes  place  near  the  centre  of 
the  placenta  it  easily  reaches  the  external  surface  of  the  chorion  ;  and  should  it  be 
near  the  point  where  the  principal  branches  of  the  cord  traverse  the  latter,  a  little 
blood  will  sometimes  be  found  to  have  penetrated  to  a  greater  or  less  extent  the 
tissues  which  surround  the  umbilical  arteries  and  vein  at  the  root  of  the  cord. 
This  condition  has  already  been  described  in  several  cases,  of  which  one  published 
by  M.  Gendrin  is  very  interesting  ;  the  cord,  for  the  distance  of  two  or  three  inches 
from  the  cavity  in  the  placenta  was  infiltrated  with  blood,  and  yet  there  was  no 
evidence  of  rupture  of  either  of  the  umbilical  arteries  or  of  the  vein.  These 
irregular  cavities  in  the  substance  of  the  placenta  may  be  numerous,  or  there 
may  be  but  one;  and  in  case  there  are  several,  they  may  have  been  formed  at  the 
same  period  or  at  different  times. 

The  third  variety  is  the  most  remarkable  of  all ;  the  cavities  are  here  well  defined 
and  regular  in  form,  even  when  the  effusion  seems  to  have  occurred  but  very  re- 
cently. Usually  there  are  several  of  them,  and  judging  from  the  appearance  of  the 
blood  which  they  contain,  they  are  produced  successively.  It  is  not  uncommon  to 
find  seven  or  eight  of  them  in  the  same  placenta,  and  sometimes  there  are  twenty 
or  more.  Simpson  mentions  a  four  months'  placenta  in  which  they  were  so  numer- 
ous us  to  give  the  impression,  upon  dividing  it,  of  a  collection  of  innumerable, 
small,  rounded,  and  distinct  clots,  closely  compacted  together.  (Dlctionnaire  en  30 
volumes.)  It  is  rare  for  the  clots  to  be  larger  than  a  pigeon's  egg;  some  are  as 
small  as  millet  or  hemp  seeds,  whilst  others  are  of  intermediate  size.  They  are 
also  situated  at  various  depths  in  the  substance  of  the  placenta,  some  extending  to 
the  internal  surface,  and  others  approaching  the  uterine  surface,  upon  which  some 
of  them  open  by  a  small  and  irregular  orifice.  The  surrounding  tissue  of  the  organ 
is  in  its  normal  condition,  and  the  appearance  of  extravasation  of  blood  extends  for 
but  a  few  lines  beyond  the  boundaries  of  the  cavities.  These  regularly  formed 
clots  begin  to  lose  their  color  at  the  circumference,  so  that  at  a  certain  period  the 
cavity  exhibits  a  white,  thin  pellicle,  which  detaches  more  easily  from  the  clot 
than  from  the  placental  tissue.     (Jacquemier.) 

We  have  hitherto  said  that  the  placental  tissue  surrounding  the  javities  is  in  a 
uealthy  condition  ;  but  this  is  not  always  the  case.     It  will  be  remembered,  indeed. 


DISEASES    OF    THE    OVUM.  555 

that  it  is  not  uncommon  to  find  apoplectic  collections  in  the  centre  of  coty  .edons 
affected  with  fibrous  obliteration  of  the  villi.  (See  page  551.)  In  such  placentas 
occur  very  small,  regularly  formed  cavities,  enclosing  clots  of  blood  of  an  appear- 
ance compared  by  M.  Jacquemier  to  black  grape-seeds. 

The  blood  effused  in  the  tissue  of  the  placenta,  when  the  ovum  is  not  expelled, 
separates  into  two  portions,  one  solid,  the  other  liquid.  The  serum  disappears  by 
infiltration,  whilst  the  solid  part  forming  a  clot  contracts,  becomes  denser  and 
somewhat  smaller,  and  gradually  loses  its  color.  The  importance  of  the  consecu- 
tive changes  in  the  effused  blood  has,  however,  been  greatly  exaggerated;  thus  it 
was  supposed  that  the  transformation  might  be  so  complete  as  to  produce  whitish 
and  homogeneous  masses  resembling  concrete  pus  or  tuberculous  matter,  but  it  is 
evident  that  in  such  cases  effects  have  been  attributed  to  placental  apoplexy  which 
were  really  caused  by  fibrous  obliteration  of  the  villi.     (See  page  550.) 

We  have  said  that  when  utero-placental  hemorrhage  occurs  in  the  first  half  of 
pregnancy,  it  is  occasioned  by  the  rupture  of  some  of  the  maternal  vessels,  gener- 
ally the  veins,  and  that  it  very  rarely  proceeds  from  the  umbilical  vessels.  We 
think  that  the  same  observation  applies  to  placental  apoplexy. 

The  various  kinds  of  apoplectic  formations  in  the  placenta  may  coincide  with  the 
lesion  met  with  in  uterine  hemorrhages,  whether  internal  or  external ;  that  is  to 
say,  with  a  partial  or  complete  detachment  of  the  placenta  and  the  presence  of  a 
clot  of  greater  or  less  size  in  the  artificial  cavity  thus  formed,  together  with  streaks 
of  coagulated  blood  stretching  away  to  the  cervix,  and  situated  between  the  internal 
surface  of  the  uterus  and  the  uterine  decidua.  The  ovum  is  then  expelled  prema- 
turely, with  the  symptoms  of  an  ordinary  uterine  hemorrhage.  Effusions  within 
the  placenta,  however,  rarely  occasion  such  extensive  lesions,  but  are  almost  always 
limited  and  compatible  with  the  continuance  of  gestation.  The  effect  of  placental 
apoplexy,  moreover,  varies  with  the  period  of  gestation  at  which  it  occurs,  as  also 
with  the  number  and  extent  of  the  effusions  and  the  more  or  less  frequeut  occur- 
rence of  the  accidents.  If  the  points  of  effusion  are  small  and  few  in  number,  a 
considerable  part  of  the  placenta  retains  its  natural  structure  and  capacity  for  the 
fulfilment  of  its  functions  ;  in  this  case  not  only  will  the  foetus  continue  to  live,  but 
its  nutrition  will  suffer  little  or  not  at  all.  Under  opposite  circumstances,  if  it 
should  not  die,  it  will  be  born  feeble,  puny,  and  emaciated.  Should  the  apoplectic 
attacks  recur  at  short  intervals,  they  will  often  produce,  in  spite  of  all  that  can  be 
done,  gradual  diminution  of  the  motions  of  the  child  and  of  the  pulsations  of  its 
heart,  and  the  final  cessation  of  both.  In  these  unfortunate  cases,  it  is  not  uncom- 
mon for  both  the  mother  and  the  accoucheur  to  be  obliged  to  witness,  as  it  were. 
the  sufferings  and  death  of  the  child.     [Dictionnaire  en  30  volumes.) 

Apoplectic  effusions  in  the  placenta  are  rarely  betrayed  by  any  symptoms,  pro- 
vided the  hemorrhage  is  limited  in  amount.  In  some  cases,  most  of  the  indications 
of  moderate  internal  hemorrhage  are  observed,  though  its  occurrence  will  be  rather 
a  matter  of  suspicion  than  of  certainty,  unless  the  patient  has  sufl'ered  from  the 
affection  several  times  previously;  for  it  is  by  no  means  rare  for  the  same  woman 
to  miscarry  several  times  consecutively,  and  always  from  the  same  cause;  and  if 
she  should  be  delivered  at  term,  a  number  of  effusions,  both  old  and  recent,  will  be 
found  in  the  placenta.     (Jacquemier.) 

Supposing  there  is  reason  to  fear  the  occurrence  of  placental  apoplexy,  and 
especially  if  the  woman  is  predisposed  to  the  affection,  the  prophylactic  treatment 
had  recourse  to  in  cases  of  uterine  hemorrhage  during  pregnancy,  will  be  indi- 
cated (see  Abortion).  As  measures  offering  the  greatest  chance  of  success,  we 
would  mention  absolute  rest  and  small  bleedings,  to  be  repeated  at  longer  or 
shorter  intervals. 


556  PATHOLOGY    OF    PREGNANCY. 

CHAPTER    IV. 

DISEASES    AND   DEATH   OF  THE   FCETUS. 

\  1.  Diseases  of  the  Fan  >. 

Although  the  diseases  of  the  embryo  and  foetus  during  intra-uterine  life  are 
numerous,  they  are  very  little  known.  As  it  does  not  enter  into  the  plan  of  this 
work  to  treat  fully  of  subjects  coming  under  this  head,  the  history  of  monstrosities 
and  whatever  else  belongs  to  teratology  will  be  laid  aside,  and  we  will  merely  pre- 
sent succinctly  such  diseases  as  are  most  interesting  to  the  accoucheur  on  account 
of  their  endangering  or  destroying  the  life  of  the  child.  As  we  even  think  it  best 
to  defer  the  account  of  such  as  might  obstruct  natural  delivery,  until  we  come  to 
treat  of  dystocia,  our  task  for  the  present  will  be  quite  a  limited  one. 

1.  Inflammation.  —  Traces  of  inflammation  have  been  detected  in  various  organs 
of  the  foetus.  As  the  most  important  we  would  mention  peritonitis,  which  was 
made  the  subject  of  a  special  treatise  by  our  colleague  and  friend  Dr.  Lorain.  It 
was  most  frequently  observed  in  lying-in  hospitals  during  the  prevalence  of  puer- 
peral fever. 

The  pleura  and  lungs  are  sometimes  attacked  with  inflammation,  though  less 
frequently.  But  although  rare  in  the  human  species,  it  is  very  common  in  ani- 
mals affected  with  epizootic  pneumonia,  —  a  fact  to  which  I  called  attention  in  my 
paper  on  puerperal  fever. 

2.  Fevers.  —  It  would  seem  that  the  eruptive  fevers  may  be  communicated  by  the 
mother  to  the  child.  There  can  be  no  doubt  of  the  fact  as  regards  variola,  and  we 
have  nothing  to  add  here  to  what  has  been  said  elsewhere  (see  pages  446  and  447) 
on  the  subject;  and  the  same  remark  applies  to  intermittent  fever.    (See  page  445.) 

3.  Icterus.  —  Several  observers  have  reported  cases  of  women  having  icterus 
giving  birth  to  children  affected  with  the  same  disease,  the  waters  also  being  of  a 
yellow  color.  These  are,  however,  exceptional  cases,  as  it  is  far  more  common  for 
children  born  of  jaundiced  mothers  to  be  free  from  any  abnormal  color.  (See 
page  451.) 

4.  Syphilis.  —  We  have  already  said  that  syphilis  may  be  inherited.  The  foetus 
thus  affected  usually  undergoes  a  very  regular  development;  and  not  until  some 
weeks  or  months  have  elapsed  after  its  birth,  do  the  accidents  appear  which,  there- 
fore, it  does  not  fall  within  our  province  to  describe.  This,  however,  is  not  always 
the  case,  for  it  is  by  no  means  rare  for  the  syphilitic  foetus  to  be  born  prematurely 
or  even  to  die  before  birth.  These  children,  like  the  former,  when  examined  im- 
mediately after  delivery,  generally  exhibit  no  lesion  which  can  be  attributed  to 
syphilis,  though  in  some,  traces  of  the  disease  are  evident,  the  most  common  being 
pemphigus  of  the  palms  of  the  hands  and  soles  of  the  feet.  When  the  bullae  are 
perfect,  the  eruption  is  easily  recognized,  but  they  are  almost  always  ruptured  and 
their  place  occupied  by  rounded  erosions  with  elevated  epidermis.  Still,  they 
have  a  characteristic  look.  Pemphigus  is  more  difficult  to  recognize  when  the 
eruption  is  beginning:  it  then  appears  in  the  form  of  small,  red,  and  barely  pro- 
jecting spots,  marked  in  the  centre  with  a  whitish  point,  due,  doubtless,  to  a  slight 
elevation  of  the  epidermis.  I  have  met  with  two  cases  of  this  kind,  which  are 
represented  in  wax  models  deposited  in  the  hospital  of  the  Clinique,  and  the  re- 
ports of  which  were  published  by  Dr.  Bernardot  [Theses  de  Strasbourg). 

Autopsies  of  the  children  sometimes  reveal  visceral  lesions  due  to  syphilis,  such 
as  certain  alterations  of  the  thymus  gland,  lungs,  and  liver.  Prof.  Dubois  was 
the  first  to  call  attention  to  syphilitic  alteration  of  the  thymus  gland.  Externally 
the  affected  organ  seems  healthy,  but  if  cut  open  and  squeezed,  a  whitish  fluid 
resembling  pus  exudes  from  it.     When  the  lung  is  the  seat  of  the  lesions,  these 


DISEASES     AND     DEATH     OF     THE     FOETUS  657 

consist  of  indurated  nodules  varying  in  number  and  size,  and  of  abjut  th  =  c  msist- 
ence  of  the  liver,  as  stated  in  a  detailed  account  of  the  affection  by  Prof.  Depaul. 
Some  of  these  indurated  masses  project  beneath  the  pleura,  under  which  circum- 
stances they  present  quite  a  deep-yellow  hue.  At  a  later  period  they  undergo 
softening  and  have  at  their  centre  a  cavity  containing  a  fluid  of  a  sero-puruleiu 
appearance.  The  lesions  of  the  liver  have  been  well  studied  by  M.  Gubler,  whc 
describes  them  as  being  sometimes  general,  sometimes  partial,  and  characterized 
by  spaces  of  indurated  yellowish  hepatic  tissue,  whose  normal  structure  is  infil- 
trated with  fibro-plastic  elements  and  an  albuminous  fluid  resembling  the  serum 
of  the  blood.  The  indurations  are  distinguished  from  the  healthy  tissue  of  the 
organ  by  their  contour,  hardness,  and  resistance  to  the  finest  injections. 

5.  Dropsies.  —  Hydrocephalus,  hydrorachis,  ascites,  and  cysts  are  affections  to 
which  the  foetus  is  quite  liable;  but  as  they  often  cause  difficulty  during  labor,  they 
will  be  treated  of  under  the  head  of  dystocia.     (See  Dystocia.) 

6.  Spontaneous  Fractures.  —  Cases  have  been  reported  of  spontaneous  fractures, 
almost  aiways  multiple  upon  the  same  foetus.  Chaussier  mentions  a  child  born  at 
the  Maternity  Hospital,  in  1803,  after  a  rapid  and  easy  labor,  during  which  no 
force  had  been  applied  to  it,  which  had  forty-three  fractures,  involving  the  cranium 
as  well  as  other  bones.  Some  of  the  fractures  were  recent,  in  some  callus  was 
forming,  and  others  were  thoroughly  consolidated.  Another  case,  cited  by  the  same 
observer,  is  still  more  extraordinary.  The  child  in  question,  which  was  born  after 
an  extremely  short  and  easy  labor,  in  a  state  of  debility  and  of  a  bluish  color,  ex- 
pired in  a  short  time.  Attention  was  attracted  to  it  by  its  extreme  shortness  and 
an  unusual  mobility  in  the  continuity  of  its  bones.  One  hundred  and  thirteen 
fractures  were  counted  by  Chaussier,  involving  the  different  bones  of  the  cranium, 
chest,  and  limbs  (Jacquemier).  The  causes  of  this  singular  lesion  are  unknown; 
it  is  most  probably  due  rather  to  arrested  development  of  the  bony  tissue  than  to 
fracture  properly  so  called. 

7.  Complete  or  Incomplete  Amputation  of  the  Limbs.  —  Cases  not  less  curious  than 
the  preceding  are  those  in  which  the  children  are  born  with  limbs  amputated  at 
various  heights,  and  having  a  cicatrix  at  the  centre  of  the  stump.  Chaussier  saw 
three  deprived  of  the  hand  and  a  portion  of  the  forearm.  In  one  of  these  cases,  a 
small  bony  cylinder  found  on  the  foetal  surface  of  the  placenta  was  recognized  as  a 
portion  of  the  radius.  The  stump,  undergoing  cicatrization,  was  covered  at  its 
centre  with  granulations.  Watkinson,  in  1824,  attended  a  woman  in  her  first  labor 
who  had  experienced  nothing  unusual  during  her  pregnancy.  The  child  was 
born  prematurely,  and  lived  but  twenty  minutes.  Its  left  leg  appeared  to  have 
been  amputated  just  above  the  malleoli.  The  foot,  smaller  than  the  other,  was 
found  in  the  vagina,  but  presented  no  appearance  of  gangrene  or  alteration  of  color 
or  consistency.  The  two  divided  surfaces  (of  the  foot  and  of  the  limb)  were  almost 
entirely  cicatrized,  and  both  presented  small  projections  formed  by  the  ends  of  the 
bones.  Montgomery,  in  a  work  on  this  subject,  relates  two  cases  very  similar  to 
the  preceding,  in  which  the  detached  feet  were  expelled  before  the  child.  Cicatri- 
zation was  complete  in  one,  and  far  advanced  in  the  other.  (Jacquemier.)  It  would 
be  easy,  though  I  think  useless,  to  mention  other  examples  of  this  species  of 
deformity. 

Spontaneous  amputation  is  sometimes  incomplete;  that  is  to  say,  grooves  of 
greater  or  less  depth,  occasionally  extending  to  the  bones,  are  observed  upon  the 
limits. 

What  is  the  cause  of  this  singular  lesion  ?  Some  have  supposed  it  due  to  circulai 
turns  of  the  cord  around  the  limbs,  acting  as  does  a  ligature  around  the  pedicle  of  a 
tumor  ;  but  it  is  very  difficult  to  suppose  that  the  cord  could  be  drawn  tight  enough 
to  amputate  a  limb  without  arresting  the  placental  circulation  ai  the  same  time. 
Montgomery's   explanation  is  much  more   probable;    be  supposes  the  amputation  to 


558  PATHOLOGY  OF  PREGNANCY. 

be  effected  by  constricting  materials  other  than  the  cord.  In  several  cases  were 
found  fibrous  bands,  whose  origin  it  is  difficult  to  determine,  which  constricted  the 
limbs  as  would  real  cords,  and  which  would  have  occasioned  complete  or  incomplete 
amputation  according  to  the  degree  of  constriction.  It  must,  however,  be  said  that 
these  bands  are  not  always  to  be  found,  so  that  the  etiology  of  spontaneous  ampu- 
tation is  very  uncertain.  It  cannot  be  affirmed,  says  M.  Jacquemier,  that  they  are 
always  the  mechanical  effect  of  a  constricting  agent;  they  may  possibly  be  due  to 
a  deep-seated  local  lesion  and  to  the  constriction  induced  in  the  skin  by  an  exten- 
sive cicatricial  action. 

\  -.  Death  of  the  Fcetus. 

The  causes  which  destroy  the  life  of  the  embryo  and  foetus  are  numerous,  but  we 
shall  not  attempt  to  recapitulate  them  here,  referring  the  reader  to  the  chapters 
which  treat  respectively  of  the  diseases  of  the  mother  and  of  the  ovum  and  foetus, 
as  also  to  the  article  on  abortion.  It  must,  however,  be  confessed  that  it  is  often 
impossible  to  determine  the  cause  of  death  or  to  discover  anything  which  can 
explain  it  in  a  satisfactory  manner.  Some  of  these  unknown  causes  have  attracted 
attention  by  the  persistence  with  which  they  continue  to  act  in  the  same  woman 
through  several  successive  pregnancies.  I  myself  knew  a  woman  in  good  health, 
who,  on  thirteen  consecutive  occasions,  and  without  any  discoverable  reason,  lost 
her  child  during  the  last  month  of  gestation.  Since  Denman's  time,  it  has  been 
supposed  that  in  these  cases  recourse  might  be  had  successfully  to  the  induction  of 
premature  labor.  We  would  also  revert  to  the  fact  (see  page  271)  that  in  twin 
pregnancies  one  foetus  sometimes  dies  and  assumes  a  mummy-like  condition,  whilst 
the  other  undergoes  its  regular  development.  This  occurrence  can  only  be  known 
after  delivery. 

It  is  not  always  easy  to  assure  ourselves  that  the  fcetus  is  dead ;  it  will  sometimes 
be  suspected  when  it  ceases  to  move,  especially  after  having  been  unusually  active. 
At  other  times,  the  spontaneous  motions  gradually  grow  less  frequent  and  weaker, 
and  finally  cease.  Too  much  importance  ought  not,  however,  to  be  attributed  to 
this  sign,  because  the  fcetal  motions  present  numerous  anomalies,  even  in  the  midst 
of  the  most  perfect  health.  The  surest  indications  are  derived  from  auscultation 
of  the  foetal  heart.  "In  regarding  the  subject  from  this  point  of  view/'  says  M. 
Depaul,  "we  must  set  aside  the  three  first  months  of  gestation,  during  which  the 
sounds  of  the  heart  cannot  be  heard,  and  also  remember  that  in  many  cases  it  is 
impossible  to  perceive  them  before  the  expiration  of  the  fourth  month.  During  the 
last  half  of  gestation,  the  conditions  are  altogether  different,  success  in  the  stetho- 
scopic  examination  being  the  rule,  whilst  failure  should  be  regarded  as  a  very  rare 
exception.  Inasmuch,  however,  as  this  exception  may  exist,  it  is  impossible  to 
attribute  an  absolute  value  to  auscultation  of  the  foetal  heart  as  a  means  of  deter- 
mining whether  the  child  be  living  or  dead.  It  would  be  a  great  mistake,  however, 
not  to  regard  it  as  an  extremely  valuable  means,  since,  in  the  immense  majority  of 
cases,  it  leads  to  probabilities  which  amount  almost  to  certainty,  and  consequently 
allows  questions  of  the  highest  practical  interest  to  be  solved."  (Depaul,  Traite 
d' Auscultation.)  Out  of  67  women,  more  than  five  months  pregnant,  in  whom  M. 
Depaul  was  unable  to  hear  the  pulsations  of  the  heart,  but  three  were  delivered  of 
living  children.] 

Further,  the  phenomena  experienced  by  the  mother  after  the  deatli  of  the 
foetus  are  very  singular  in  these  cases :  the  abdomen  collapses  instead  of 
increasing  in  size;  the  breasts,  which  had  become  developed,  shrink  ;  the 
woman  suffers  from  a  sensation  of  weight  in  the  loins,  and  an  unusual 
pressure  in  the  lower  part  of  the  abdomen  ;  an  inert  body  in  the  uterus 
obeys  the  laws  of  gravity  and  fails  to  whichever  side  the  woman  turns  in  bed. 


DISEASES    AND    DEATH    OF    THE    FCETUS.  559 

OLher  symptoms  are  soon  added  to  the  foregoing.  If  the  gestation  is 
somewhat  advanced,  everything  passes  off  absolutely  as  if  the  expulsion 
of  the  embryo  had  occurred,  only  excepting  the  discharge  of  the  lochia: 
thus,  in  the  course  of  forty-eight  to  sixty  hours  after  its  death,  the  breasts 
swell  up,  the  phenomena  of  milk  fever  are  manifested,  and  the  lacteal  secre- 
tion is  fully  established,  after  which  the  breasts  again  subside,  and  the 
usual  order  is  resumed.  As  a  general  rule,  the  prolonged  retention  of  a 
dead  infant  does  not  produce  any  disastrous  result  to  the  mother,  and  I 
suspect  that  writers  have  greatly  exaggerated  on  this  point :  they  say, 
indeed,  that  the  woman  becomes  depressed,  uneasy,  and  of  a  fretful  temper  ; 
that  she  experiences  lassitude,  alternations  of  heat  and  cold,  oppression  at 
the  epigastrium,  headache,  syncope,  palpitations  of  the  heart;  her  face  is 
pale,  the  eyes  dull  and  surrounded  by  a  livid  circle,  the  breath  fetid,  pulse 
frequent  and  irregular:  in  a  word,  all  these  general  phenomena  of  a  slow 
fever  have  been  considered  by  them  as  so  many  rational  signs  of  the  child's 
death.  But  these  symptoms  are  certainly  absent  in  the  majority  of  cases  ; 
for  most  women,  after  we  have  succeeded  in  calming  their  fears,  experience 
nothing  of  the  kind,  and  I  have  known  many  of  them  to  carry  a  dead  child 
for  several  months  without  even  suspecting  it,  and  some  even  to  congrat- 
ulate themselves  upon  the  amelioration  of  their  general  condition,  in  con- 
sequence of  the  sudden  disappearance  of  the  sympathetic  disorders  of  preg- 
nancy. At  an  indeterminate  period  labor  comes  on,  and  the  abortion  is 
effected. 

By  examining  the  dead  foetus,  we  may  learn  why  its  prolonged  sojourn 
in  the  uterine  cavity  has  been  wholly  innoxious  to  the  mother.  In  fact, 
the  infant  is  not  putrefied,  as  is  proved  by  its  having  no  bad  odor  ;  the  solid 
parts  undergo  a  peculiar  transformation,  and  the  body  is  somewhat  analo- 
gous in  appearance  to  one  that  has  been  soaked  for  a  long  time  in  water. 

When  the  foetus  remains  in  the  uterus  thoroughly  protected  from  the  air, 
it  does  not  putrefy,  but  undergoes  maceration.  M.  Martin  (of  Lyons)  judi- 
ciously remarks :  "  The  kind  of  alteration  which  a  dead  child  undergoes  in 
the  womb,  will  also  vary  according  to  the  period  of  pregnancy  at  which  it 
ceased  to  live.  Thus,  in  the  early  stage  of  its  formation,  when  its  organi- 
zation has  but  little  consistence,  and  approaches  the  mucilaginous  state,  it 
dissolves  in  the  waters  of  the  amnios,  which  then  become  thicker  and  assume 
the  characters  of  a  gummy  solution,  and  no  further  trace  of  the  embryo  is 
found  in  the  amniotic  cavity.  But  at  a  period  somewhat  later,  that  is,  from 
the  second  to  the  fifth  month,  it  withers  away,  becomes  shrivelled  and  dried 
up,  and  looks  like  a  little  mummy  of  a  yellow  color,  or  like  a  foetus  pre- 
served for  a  long  time  in  alcohol.  Not  unfrequently,  the  placenta  likewise 
participates  in  this  state  of  desiccation,  the  liquor  amnii  disappearing  and 
being  replaced  by  a  thick  and  apparently  an  earthy  humor,  which  incrusts 
the  fetus."     (Memoires  de  Med.  et  de  Chir.  Prat,  page  (J6.) 

After  the  fifth  month,  a  child  putrefied  in  the  womb  presents  so  different 
an  aspect  from  one  that  has  undergone  the  same  process  in  the  open  air, 
that  it  is  only  necessary  to  observe  this  particular  condition  once  or  twice, 
never  to  mistake  it  afterwards. 

Imagine  the  little  defunct  stretched  on  a  table:  the  flaccidity  of  it?  soft 


560  PATHOLOGY   OF    PREGNANCY. 

parts  is  then  so  very  striking,  that  the  head  becomes  flattened  under  tht 
influence  of  its  own  weight,  whatever  position  may  lie  given  to  it;  the  soft 
parts  on  the  thorax  exhibit  the  form  of  the  ribs;  the  front  of  the  chest  is 
very  much  flattened,  the  abdomen  sunken  and  nearly  hollow  about  the 
navel,  and  forming  two  large  rounded  projections  on  the  flanks;  even  the 
extremities  exhibit  the  same  state  of  collapse.  The  discoloration  of  the 
skin  is  particularly  remarkable,  although  often  confined  to  the  abdomen,  at 
least  when  the  sojourn  of  the  foetus  in  the  womb  has  not  been  very  long. 
The  skin  of  this  part  has  a  brownish-red  shade,  without  the  least  appear- 
ance of  a  greenish  hue.  This  tint  is  less  marked  on  the  chest,  neck,  head, 
and  limbs;  nevertheless,  it  exists  there  also.  But  this  is  not  the  brownish 
hue  that  often  succeeds  a  green  putrefaction  ;  it  is  a  much  clearer  reddish- 
brown.  The  cord  is  no  longer  twisted,  but  it  forms  a  true  fleshy  cylinder, 
of  a  reddish  color,  soft,  and  saturated  with  a  brown  fluid.  The  epidermis 
is  detached  from  a  considerable  part  of  the  surface,  and  may  be  easily  sepa- 
rated from  those  places  where  it  is  still  adherent,  thus  leaving  the  humid 
dermis  exposed,  which  is  as  glutinous  as  if  it  were  lubricated  by  a  mucous 
fluid  ;  and  then  the  true  skin  has  a  bright  rose  color.  The  epidermis  on  the 
feet  and  hands  is  white  and  thick,  and  looks  as  if  it  had  been  corrugated  by 
cataplasms.  The  subcutaneous  cellular  tissue  is  infiltrated  with  a  reddish 
serosity,  which  is  also  seen  between  the  muscles,  and  sometimes  in  the  sub- 
stance of  the  muscular  tissue  itself.  The  bones  of  the  head  are  feebly  held 
together,  their  periosteum  may  be  readily  detached,  and  they  are  movable 
on  each  other.  The  cellular  tissue  underneath  the  hairy  scalp  is  infiltrated 
with  a  thick  serosity,  resembling  currant-jelly  in  appearance.  Finally, 
whenever  we  attempt  to  move  or  raise  the  foetus,  it  slips  through  the  hands 
just  like  a  fish  that  lives  for  some  time  out  of  water,  in  consequence  of  the 
fluid  mucus  covering  its  surface.     (Devergie,  Med  Legale.} 

A  dead  foetus  is  merely  a  foreign  body  in  the  uterus,  which  will  soon  have 
to  be  discharged.  The  time  at  which  the  expulsion  will  take  place  varies 
greatly ;  sometimes  after  a  few  days  only,  sometimes  weeks  will  elapse,  and 
occasionally  a  month  or  more.  The  symptoms  which  arise  will  be  those  of 
abortion  or  labor,  according  to  the  age  of  the  foetus  at  the  time  of  its  death. 
(See  Abortion.) 


CHAPTER  y. 

OF    ABORTION. 

The  term  abortion  has  been  applied  to  the  expulsion  of  the  foetus  from  the 
womb,  where  this  occurs  at  a  period  of  pregnancy  when  the  product  of  con- 
ception is  not  yet  viable:  that  is  to  say,  an  abortion  may  take  place  at  any 
time  between  the  commencement  of  pregnancy  and  the  end  of  the  sixth 
month.  The  ancients  applied  the  term  effluxio  to  this  accident,  if  it  hap- 
pened before  the  seventh  day.1  The  term  premature  labor  is  usually  applied 
to  expulsion  occurring  after  the  sixth  or  seventh  month. 

\\  e  place  i  lie  period  of  viability  at  the  seventh  month,  though  well  aware  that  some 
reported  where  foetuses  born  at  six,  or  five,  or  even  four  months,  have 
lived  ;    but  such  instances,  besides   not  having  all  the  authenticity  desirable,  are  too 
rare  to  invalidate  the  general  law. 


OF    ABORTION.  561 

In  a  recent  and  very  remarkable  article  by  M.  Guilkmot,  this  author 
admits  three  varieties  of  abortion,  founded  on  the  period  of  its  occurrence : 
thus,  ovular  abortion  is  the  title  he  gives  when  it  takes  place  before  the 
twentieth  day;  embryonic,  if  prior  to  the  third  month;  and/ceto/,  from  the 
latter  date  up  to  the  sixth  month  of  gestation. 

Persons  out  of  the  profession,  further,  designate  abortion  under  the  title 
of  miscarriage  (fausse  couche). 

Abortions  are  much  more  frequent  in  the  first  two  or  three  months  than 
at  any  other1  period.  The  great  vascularity  of  the  uterine  mucous  mem- 
brane, become  the  decidua,  and  the  ease  with  which  effusions  of  blood  may 
take  place  into  the  space  which  originally  exists  between  the  chorion  and 
the  reflected  portion  of  the  decidua  (see  page  552),  sufficiently  ex- 
plain the  frequency  of  hemorrhage,  and  consequently  of  abortion  in  the 
early  months.  In  making  this  remark,  I  am  not  ignorant  that  Madame 
Lachapelle  has  given  a  different  view,  but  it  was  because  her  position  at  the 
Maternity  rarely  furnished  her  with  opportunities  of  observing  abortions 
prior  to  the  fourth  or  fifth  month,  for  females  do  not  usually  go  to  the  hos- 
pitals on  account  of  the  miscarriages  of  the  first  five  or  six  weeks  of  gesta- 
tion ;  and  though  other  persons  have  since  adopted  her  opinion,  it  is  doubt- 
less owing  to  the  difficulty  of  diagnosis,  and  to  the  errors  of  females  them- 
selves, who,  supposing  they  have  only  a  simple  retardation  of  the  menses, 
allow  an  abortion  to  pass  away  in  the  early  stages  unperceived. 

Morgagni  and  Desormeaux  supposed  that  abortion  of  foetuses  belonging 
to  the  female  sex  are  more  numerous  than  of  males,  and  I  do  not  know 
whether  the  vulgar  opinion  opposed  to  this  is  true  or  false  ;  but  certain  it  is, 
that  at  term  the  boys  exceed  the  girls  in  the  proportion  of  sixteen  to  fifteen, 
which  would  seem  to  prove  that  female  abortions  are  the  most  numerous  ; 
and  besides,  it  is  possible  that  the  difficulty  of  distinguishing  the  sex  in  the 
earlier  periods  of  intra-uterine  life  may  have  had  some  influence  in  creating 
the  popular  error. 

The  history  of  abortion  evidently  includes  the  study  of  the  causes  produc- 
ing it,  the  symptoms  and  consequences  which  may  arise,  the  signs  by  which 
it  may  be  detected,  and  the  more  suitable  indications  for  preventing  or 
opposing  it. 

ARTICLE    I. 

CAUSES. 

Considered  in  relation  to  its  determining  causes,  abortion  may  be  divided 
into  the  spontaneous  and  accidental. 

The  term  provoked  has  also  been  used,  where  the  abortion  has  resulted 
either  from  criminal  efforts,  or  from  the  measures  adopted  by  the  scientific 
physician  with  a  laudable  object.  We  shall  retain  this  division  for  etio- 
logical purposes. 

§  1.  Causes  of  Spontaneous  Abortion. 

[The  causes  of  spontaneous  abortion  may  be  sought  for  either:  1.  In  the  father. 
2.  In  the  genera]  health  and  habits  of  the  mother.  .">.  In  the  state  of  the  womb 
and  its  appendages.     1.  En  diseases  of  the  ovum.    o.  [n  diseases  of  the  foetus. 

80 


562  PATHOLOGY    OF    PREGNANCY. 

1.  Causes  due  to  the  father. — At  first  thought,  says  M.  Ferdut,  coosidering  the  tran- 
sitory pari  taken  by  the  lather,  it  would  not  seem  probable  that  be  could  be  the  cause 
of  a  miscarriage  which  should  not  take  place  until  after  two  or  three  months.  Such, 
however,  is  the  fact,  as  is  proven  by  the  experience  of  women  who  invariably  miscar- 
ried during  the  life  of  a  first  husband,  but  who  were  several  times  delivered  safely  at 
term  after  a  second  marriage. 

The  influence  of  the  father  in  causing  abortion  may  be  exerted  in  two  ways  — 
by  his  constitution  and  by  his  diseases.  Ova,  fecundated  by  men  who  are  either 
too  old  or  too  young,  rarely  become,  it  is  said,  fully  developed,  and  the  same  remark 
applies  to  those  whose  constitution  is  exhausted  by  debauchery  or  excesses  of  any 
kind.  From  M.  Devillier's  article  in  the  new  Dictionary,  it  would  seem,  however, 
that  he  thinks  the  idea  of  an  influence  exerted  by  the  father  in  the  causation  of 
abortion  should  be  received  with  considerable  reserve.  We  would  remark,  says 
this  author,  that  the  procreative  power  is  entirely  distinct  from  that  of  develop- 
ment. If  a  man,  under  the  conditions  mentioned,  has  been  able  to  fecundate  a 
robust  and  healthy  woman,  the  generative  influence  once  having  been  communi- 
cated by  him,  the  development  of  the  product  of  conception  would  thenceforth  be 
almost  wholly  under  the  influence  of  the  vitality  of  the  woman ;  so  that  it  is  prob- 
able that  the  influence  of  the  father  would  at  least  be  very  limited.  (Devilliers.) 
It  will  also  be  understood  that  diseases  of  the  father  may,  to  a  certain  extent,  be 
transmitted  to  the  foetus  and  produce  abortion.  Of  all  these  morbid  conditions, 
syphilis  exerts  a  more  deleterious  influence  upon  the  duration  of  pregnancy  than 
any  other,  though,  it  should  be  stated,  all  authors  do  not  agree  upon  the  subject. 
We  believe,  at  any  rate,  that  we  would  be  correct  in  saying  that,  in  some  cases,  the 
father,  and  not  the  mother,  ought  to  be  subjected  to  a  prophylactic  treatment.] 

2.  General  Condition  of  the  Mother. — "Women  of  a  plethoric  habit,  and 
having  copious  menstrual  discharges,  are  greatly  exposed  to  abortion 
during  the  early  months  of  gestation;  in  fact,  we  have  already  alluded 
to  those  hemorrhagic  molimens  that  appear!  in  them  at  every  monthly 
period.  Again,  nervous,  or  very  irritable  women,  those  who  are  strongly 
affected  by  moral  impressions,  such  as  anger,  chagrin,  &c. ;  females  of  a 
sedentary  habit,  who  are  always  shut  up  in  the  shops,  as  well  as  those 
that  follow  an  indolent  life,  passing  their  time  at  balls  or  soirees,  and 
in  light  reading,  also  abort  very  frequently.  The  surrounding  atmo- 
spheric conditions  are  not  wholly  without  influence  in  the  production  of 
abortion  ;  in  fact,  we  may  refer  to  this  cause  those  epidemic  miscarriages 
spoken  of  by  most  authors.  Mountainous  countries,  where  the  air  is  bleak, 
are  considered  as  being  favorable  to  their  production  ;  for,  according  to  the 
report  of  Saucerotte,  the  women  inhabiting  the  summit  of  the  Vosges  are 
very  subject  to  abortion,  and  they  are  in  the  constant  habit  of  descending 
into  the  adjacent  plains  to  avoid  this  accident. 

Acute  diseases,  especially  the  eruptive  fevers,  and  small-pox  most  par- 
ticularly, occurring  in  the  course  of  pregnancy,  abdominal  or  thoracic 
affections,  and  recent  cutaneous  diseases,  often  give  rise  to  miscarriage. 
Syphilis  in  the  mother  has  the  most  disastrous  influence  upon  the  progress 
of  gestation,  and  even  the  mercurial  treatment  does  not  always  secure  from 
abortion.  Some  writers  think  thai  the  administration  of  mercury  endan- 
gers the  life  of  the  foetus.  Their  opinion  is,  however,  rejected  by  most 
modem  writers  upon  syphilis,  almost  all  of  whom  regard  the  antivenereal 
treatment  begun  at  the  outset  of  pregnancy,  as  the  besl  means  of  preventing 


OF    ABORTION.  563 

abortion.  The  numerous  facta  which  have  come  under  our  own  observa- 
tion, have  changed  our  opinion  upon  this  point,  and  we  now  think  it  most 
prudent  to  begin  the  treatment  as  soon  as  possible. 

It  often  happens,  indeed,  that,  notwithstanding  the  existence  of  constitu- 
tional syphilis,  when  the  mother  has  been  treated  properly  and  sufficiently 
long,  the  pregnancy  continues  to  the  full  period,  and  the  child  escapes  the 
infection  to  which  it  seemed  fated.     (Duval.) 

According  to  the  author  just  quoted,  it  would  seem  that  much  depends 
upon  the  length  of  time  which  the  disease  has  lasted.  "  Numerous  observa- 
tions," he  says,  "show  that  syphilis  at  its  commencement  does  not  usually 
endanger  the  product  of  conception,  but  that,  at  a  more  advanced  period, 
it  involves  the  greatest  peril."  It  should  also  be  remembered  that  Dr. 
Paul's  researches  have  shown  that  lead-poisoning  may  likewise  produce 
abortion. 

The  convulsive  diseases  may  occasion  miscarriage  either  by  provoking 
uterine  contractions,  or  by  directly  destroying  the  child.     (See  Eclampsia.) 

3.  Diseases  of  the  Womb  and  its  Appendages. — The  causes  dependent  on 
the  uterus  are  referable  either  to  a  particular  state  of  that  organ,  or  to 
a  peculiar  habit  of  the  body,  the  influence  of  which  is  reflected  back 
on  the  womb.  The  following  are  given  as  causes  of  abortion  dependent 
on  this  source:  An  excessive  rigidity  of  the  uterine  fibres,  and  their 
consequent  resistance  to  dilatation ;  an  unusual  contractility  and  sensi- 
bility of  the  organ,  and  too  great  a  laxity  and  weakness  in  the  uterine 
neck.  I  willingly  admit  that,  in  certain  females,  the  excessive  sensibility 
of  the  uterine  fibre  will  scarcely  support,  without  reaction,  the  strange 
modifications  it  must  undergo  during  gestation ;  but  I  do  not  equally  com- 
prehend that  species  of  opposition,  which  some  authors  seem  desirous  of 
establishing,  between  the  resistance  on  the  part  of  the  uterine  walls  and  the 
expansive  force  of  the  ovum.  What,  indeed,  can  an  ovule,  a  few  lines  in 
diameter,  effect  against  the  thick  walls  of  the  womb  ?  or,  what  action  can  it 
possibly  have  on  the  uterine  neck,  that  will  explain  the  influence  which  has 
been  accorded  to  this  pretended  laxity  of  the  cervix,  on  the  frequency  of 
abortions  ?  The  truth  is,  the  ovum  and  the  uterus  are  developed  simulta- 
neously, but  by  forces  peculiar  to  each.  Therefore,  although  abortions  are 
more  frequent  in  primiparse,  where  the  females  have  been  married  too  young 
or  too  old ;  and  although  certain  women  abort  in  all  their  pregnancies  at 
nearly  the  same  period,  we  must  not  on  that  account  attribute  these  accidents 
to  too  great  a  resistance  of  the  body,  or  to  an  extreme  laxity  of  the  neck ; 
for  these  repeated  miscarriages,  when  not  owing  to  the  hemorrhagic  tendency 
before  alluded  to,  are  far  more  naturally  explained  by  the  excessive  irrita- 
bility of  the  womb.  The  organ  has  to  habituate  itself,  as  it  were,  to  its  new 
functions  ;  a  proof  of  which  is,  that,  in  many  females,  the  accident  is  repeated 
a  number  of  times,  but  each  time  at  a  more  advanced  period ;  so  that,  about 
the  fourth  or  fifth  pregnancy,  they  go  on  till  full  term.  Hence,  those  uterine 
congestions,  which  are  so  often  produced  in  plethoric  women  by  the  men- 
strual periodicity,  and  that  excess  of  sensibility  as  well  as  of  irritability 
observed  in  nervous  females,  are  the  only  two  predisposing  causes  that  I 
consider  as  belonging  to  the  uterus  proper,  and  even  they  are  mere  exagger- 


5 1 1  1  P A  THOLOGY    OF    P  RE( ;  X  A  N  CY. 

ations,  as  will  be  Been,  of  the  physiological  condition.    Where  abortions  are 

often  produced  by  the  influence  of  either  of  these,  they  are  designated  as 
periodical. 

But,  independently  of  these  two  causes,  we  must  evidently  take  into 
account  all  the  diseases  of  the  uterus,  whether  acute  or  chronic,  whose  action 
is  discernible :  thus,  the  various  tumors  which  may  grow  in  the  substance  of 
it<  walls,  or  may  contract  adhesions  with  them  and  the  foreign  bodies  devel- 
oped in  its  cavity,  also  ulcerations,  whether  syphilitic  or  otherwise,  which 
are  so  frequently  found  upon  the  cervix,  are  so  many  predisposing  causes, 
which  may  both  hinder  and  oppose  its  free  enlargement ;  and  lastly,  let  us 
add  the  various  displacements  of  the  uterus,  such  as  prolapsus,  lateral  obli- 
quities, or  anteversion  and  retroversion,  as  acting  in  the  same  manner. 

On  the  part  of  the  appendages,  all  the  chronic  diseases  to  which  they  are 
subject ;  the  adhesions,  deformities,  displacements,  and  their  divers  degenera- 
tions ;  the  organic  alterations  of  the  tubes,  fibrous,  polypous,  or  other  produc- 
tions seated  in  the  uterine  tissue  or  neighboring  parts  ;  unnatural  adhesions 
of  the  broad  or  the  round  ligaments,  tubes,  or  ovaries :  in  a  word,  everything 
that  can  impede  the  easy  and  free  development  of  the  womb,  must  be  re- 
garded as  occasional  causes  of  abortion.  (Madame  Boivin,  Recherches  sur 
une  cause  peu  conmie  d'avortement.) 

Finally,  an  inflammation  of  the  adjacent  organs,  particularly  the  bladder, 
rectum,  &c,  may,  through  the  irritation  thereby  communicated  to  the  uterus, 
bring  on  its  contractions.  Moreover,  the  existence  of  any  voluminous  tumor 
in  the  abdomen  must  necessarily  incommode  the  development  of  this  organ  ; 
also  the  compression  of  the  hypogastrium,  that  some  women  produce  by  the 
use  of  corsets,  may  have  the  same  effect.     , 

According  to  Peu,  we  must  add  to  these  various  sources  of  inconvenience, 
contraction  of  the  pelvis  opposing  the  distention  of  the  womb,  and  sometimes 
its  elevation  above  the  superior  strait ;  more  especially  when  the  narrow- 
ness of  the  latter  coincides  with  the  regular,  or  even  an  increased  size  of  the 
excavation. 

4.  Diseases  of  the  Ovum. — Any  of  the  diseases  of  the  ovum  may  give  rise 
to  abortion,  and  we  shall  not  repeat  what  we  have  said  concerning  them.  (See 
Diseases  of  the  Ovum).  It  will  suffice  to  mention  here  that  the  most  impor- 
tant of  these  diseases  are,  dropsy  of  the  amnion,  hydrorrhcea,  the  hydatiform 
mole,  placental  apoplexy,  and  fibro-fatty  degeneration  of  the  placenta. 

As  regards  the  insertion  of  the  placenta  over  the  neck,  I  can  scarcely 
believe  that  it  could  produce  an  abortion,  and  hence  I  imagine  that  the  cases 
cited  in  support  of  that  view  have  been  misinterpreted;  the  insertion  has 
been  considered  as  the  cause  of  the  accident  in  those  instances,  when  it  cer- 
tainly was  nothing  more  than  a  simple  coincidence.  M.  D'Outrepont  has 
advanced  the  torsion  of  the  umbilical  cord  as  a  cause  of  determining  the 
death  of  the  foetus ;  for  the  state  of  compression,  says  he,  resulting  therefrom, 
may  impede  the  circulation.  The  embryos  had  been  dead  for  a  long  time, 
in  all  the  cases  of  that  kind  observed  by  him. 

Again,  it  may  be  asked,  if  the  umbilical  cord  is  too  short,  could  it  drag 
off  or  detach  the  placenta,  or  even  be  ruptured  itself?  Now,  to  the  facts 
bearing  on  this  point,  reported  by  Mauriceau,  Stein,  &c,  M.  Guillemot  adds 


OF    ABORTION.  565 

the  following:  The  foetus  was  about  three  months  old,  the  umbilical  cord 

was  tightly  stretched  and  even  half  separated  near  its  origin  at  the  navel ; 
two  folds  of  it  encirlced  the  neck,  and  some  deep  marks  were  left  on  this 
part  from  their  pressure.  The  circulation,  he  continues,  was  therefore  inter- 
rupted in  the  cord  by  the  tension  and  compression  it  sustained ;  and  the 
strangling:  of  the  child's  neck  also  contributed  to  its  death.  M.  Deneux  has 
furnished  a  case  of  a  rupture  of  the  umbilical  vein,  and  effusion  of  its  blood 
into  the  tissue  of  the  cord  itself;  he  found  there  a  clot,  equalling  a  small  nut 
i'q  volume,  which  had  interrupted  the  circulation  in  the  umbilical  vessels  by 
its  pressure. 

Lastly,  the  disease  of  the  membranes,  and  of  the  umbilical  vesicle,  also 
prove  a  frequent  cause  of  abortion,  especially  in  the  early  stages  of  embryonic 
life  ;  for  in  more  than  two  hundred  products  of  conception,  that  had  not 
passed  beyond  the  third  month,  M.  Velpeau  generally  found  an  alteration 
of  some  part  of  the  ovum. 

5.  Diseases  and  Death  of  the  Foetus.  —  Circumstances,  which  are  often 
unknown  to  us,  may  arrest  the  development  of  the  foetus :  for  instance,  it 
may  be  affected  in  the  mother's  body,  by  those  acute  diseases  which  at  times 
beset  it  after  birth  ;  and  such  affections,  though  not  always  fatal  to  the 
new-born  infant,  are  the  most  disastrous  to  the  intra-uterine  foetus  as  they 
occur  the  nearer  to  the  period  of  fecundation.  (See  Diseases  of  the  Foetus.) 
We  may  add,  the  presence  of  several  children  as  a  cause  dependent  on  the 
child ;  in  fact,  we  have  elsewhere  seen  that  the  excessive  distention  pro- 
duced by  a  twin  pregnancy,  frequently  brings  on  premature  contractions. 
However,  the  uterus  is  rarely  developed  enough  prior  to  the  sixth  month 
to  provoke  such  an  accident,  for  this  seldom  happens  until  a  more  advanced 
stage,  and  then  it  no  longer  appertains  to  abortion  properly  so  called. 

Some  diseases  of  the  parents  may  affect  the  child ;  for  example,  a  vitiated 
spermatic  fluid  communicates  to  the  new  being  a  principle  which  does  not 
fail  sooner  or  later  to  destroy  it.  M.  Guillemot  attributed  the  numerous 
miscarriages  of  a  young  lady  who  consulted  him  to  this  cause ;  for  her  hus- 
band, although  of  a  suitable  age,  exhibited  all  the  characters  of  premature 
decrepitude.  Having  become  a  widow,  she  remarried,  was  several  times 
pregnant,  and  was  always  delivered  happily  at  full  term. 

The  mother,  also,  may  transmit  her  diseases  to  the  child.  Nothing, 
indeed,  is  more  common  than  to  find  children  presenting,  a  few  weeks  after 
birth,  evident  traces  of  the  venereal  infection  received  from  the  mother 
during  intra-uterine  life,  and  hence  we  may  conceive  that  this  hereditary 
taint  may  prove  fatal  to  the  foetus  whilst  still  within  the  womb. 

Small-pox  is  also  sometimes  communicated  from  the  mother  to  the  foetus, 
and  causes  its  death.  It  is  remarkable  that  several  circumstances  seem  to 
prove,  that  the  infection  frequently  does  not  take  place  until  after  the 
mother's  recovery.     (See  page  447.) 

In  some  cases,  the  body  of  the  mother  is  but  the  conductor  of  a  conta- 
gious principle  of  small-pox.  We  might  here  add  examples  in  addition  to 
those  already  cited  (page  447). 

Some  years  ago,  a  woman,  in  the  wards  of  Professor  Fouquier,  was  deliv- 
ered of  a  dead  child  affected  with  small-pox,  although  she  had  herself  been 


566  PATHOLOGY  OF  PREGNANCY. 

vaccinated.  Finally,  the  illustrious  Mauriceau  relates  that  his  mother 
when  in  the  last  stage  of  her  pregnancy,  had  the  misfortune  to  lose  the 
eldest  of  her  three  sons  by  small-pox,  to  whom,  notwithstanding  her  condi- 
tion, she  was  unceasing  in  her  attentions ;  and  that  at  his  birth,  which 
occurred  the  day  after  the  death  of  his  eldest  brother,  he  presented  four  or 
five  pustules  of  small-pox. 

In  short,  all  the  diseases  to  which  the  foetus  is  subject  may  be  followed 
by  abortion.     Its  death  always  produces  it. 

§  2.  Causes  of  Accidental  Abortion. 

Besides  the  causes  just  enumerated,  that  have  been  designated  by  most 
writers  as  the  predisposing  ones,  but  which,  perhaps,  would  be  more  appro- 
priately called  slow-acting  causes,  there  are  yet  some  others  that  might  be 
termed  accidental  causes :  such  as  those  which  operate  from  without,  and 
make  their  influence  more  promptly  felt.  The  latter  are  very  numerous  ; 
indeed,  on  reading  the  published  cases,  we  find  that  authors  have  considered 
all  the  moral  and  physical  excitements  that  women  are  subject  to,  as  so 
many  causes  of  abortion.  In  most  of  the  recorded  instances,  we  can  readily 
6atisfy  ourselves  that  the  observers  have  attached  too  much  importance  to 
these  occasional  causes  of  its  production  ;  for,  generally  speaking,  it  would 
have  occurred  without  them,  only,  perhaps,  a  little  later ;  and  even  here 
the  expulsion  of  the  foetus  is,  in  truth,  owing  to  the  slow  and  gradual  action 
;>f  the  predisposing  cause.  However,  there  are  some  accidental  causes 
whose  influence  is  indisputable.  For  instance,  falls,  excessive  fatigue,  too 
frequent  coition,  and  severe  contusions,  have,  in  some  instances,  produced 
immediately  a  loss  of  blood,  followed  by  abortion. 

Falls  and  contusions  may  act  in  two  ways  :  either  by  bruising  or  violently 
irritating  the  mother's  organs,  or  by  wounding  the  foetus,  and  determining 
its  death.  The  latter  has  been  denied  by  some  persons  :  but  to  the  instances 
now  known  to  science,  I  will  add  the  following  from  my  own  observation : 
A  young  woman,  six  months  pregnant,  struck  her  abdomen  violently  against 
a  table  while  walking  in  the  dark  in  her  chamber  ;  during  the  night,  the 
motions  of  the  child  were  for  a  time  quite  tumultuous,  then  they  diminished, 
and  on  the  following  morning  could  not  be  perceived  at  all.  Two  days 
afterwards  she  was  delivered  of  a  dead  child,  which  presented  an  ecchymosis 
on  its  back  as  large  as  the  palm  of  my  hand. 

Burdach  speaks  of  a  woman  who  received  a  blow  upon  the  lower  part 
of  the  abdomen,  when  in  the  sixth  month  of  her  pregnancy,  and  who  was 
delivered  of  a  child,  the  bones  of  one  of  whose  legs  and  of  a  forearm  had 
been  fractured,  and  united  at  an  acute  angle.  The  jarring  attendant  upon 
travelling  by  rail,  or  too  great  use  of  a  sewing-machine,  are  also  capable  of 
giving  rise  to  abortion. 

I  shall  not  enumerate  here  the  various  circumstances  that  have  been 
considered  as  occasional  causes ;  but,  by  way  of  showing  how  their 
importance  has  been  overrated,  I  will  merely  remark  that,  although  certain 
women,  who  are  constitutionally  predisposed  to  miscarriages,  may  abort  in 
consequence  of  a  trifling  fright,  or  the  odor  of  a  badly  snuffed  candle,  yet 
there  are  others,  on  the  contrary,  who  will  suffer  the  most  acute  moral  im- 


OF    ABORTION.  567 

pressions,  and  the  most  violent  physical  shocks,  without  any  accident  what- 
ever resulting  therefrom;  and  nothing  would  be  more  easy  than  to  bring 
forward  numbers  of  cases  in  support  of  this  proposition  ;  the  following, 
however,  may  be  sufficient :  I  had  an  opportunity  of  observing,  at  the 
Hotel  Dieu,  when  acting  as  an  "interne"  in  the  obstetrical  wards,  a  young 
girl  in  the  fifth  month  of  pregnancy,  who,  being  rendered  desperate  by  the 
desertion  of  her  lover,  cast  herself  into  the  Seine,  from  the  Pont  Neuf,  yet, 
notwithstanding  so  violent  a  shock,  the  gestation  pursued  its  regular  course. 
Again,  M.  Gendrin  speaks  of  a  young  lady  who  was  thrown  from  a  chaise 
over  the  horse's  head  by  the  animal  falling  in  his  career.  This  lady  was 
then  five  months  pregnant,  but  the  accident  did  not  prevent  her  from  reach- 
ing her  full  term.  I  met  with  a  case  precisely  similar  in  the  wife  of  a  notary 
living  near  Paris. 

I  was  consulted,  in  Sept.,  1845,  by  a  young  lady,  who  was  evidently  six 
or  seven  months  advanced.  Her  physician  had  suspected  an  inflammatory 
engorgement  of  the  womb,  and  during  the  third  or  the  fourth  month  this 
gentleman  had  applied  fifteen  leeches  on  the  neck  of  the  uterus  itself;  and, 
strange  to  say,  not  only  was  this  application  unattended  by  any  accident, 
but  the  patient  seemed  relieved  of  the  distress  and  pain  in  the  hypogas- 
trium.  And,  lastly,  is  it  necessary  to  refer  here  to  all  the  manipulations, 
and  all  the  violent  remedies,  that  some  distracted  women  make  use  of  in 
vain  to  procure  an  abortion  ? 

§  3.  Causes  on  Account  of  which  Abortion  is  artificially  produced. 

The  third  order  of  cases  still  remaining  for  our  examination  are  the  means 
of  producing  abortion.  These  must  be  distinguished  according  to  the  pro- 
posed object :  that  is,  whether,  in  producing  an  abortion,  the  indication  be  to 
relieve  the  woman  as  well  as  the  infant,  if  the  latter  is  well  developed,  from 
the  dangers  that  threaten  them  (and  we  shall  treat  of  the  means  to  be  em- 
ployed in  such  cases  when  we  speak  of  the  indications  presented  by  the 
mother's  vices  of  conformation),  or  whether,  contrary  to  all  the  laws  of 
morality,  the  design  is  to  destroy  the  foetus  in  the  body  of  its  mother,  for 
the  sole  purpose  of  concealing  the  traces  of  an  illegitimate  pregnancy.  But 
sve  have  nothing  whatever  to  say  concerning  the  measures  resorted  to  by 
criminal  hands  in  such  cases,  for,  unfortunately,  they  are  too  well  known. 

ARTICLE  II. 

SYMPTOMS   OF   ABORTION. 

The  signs  of  abortion  vary  with  the  period  of  its  occurrence,  and  alsu 
with  its  determining  cause.  Thus,  when  it  happens  in  the  early  (lavs  of 
gestation,  it  is  attended  by  but  very  few  remarkable  phenomena;  and,  in 
general,  the  pain  is  so  trifling  that  the  patient  scarcely  suffers  more  than 
from  a  difficult  menstruation.  The  first  uterine  contractions  are  sufficient 
to  produce  the  complete  separation  of  the  ovum,  the  adhesions  of  which  arc 
still  very  feeble ;  and  it  escapes  either  in  mass  or  in  shreds,  usually  sur- 
rounded by  fluid  or  half-coagulated  blood,  and,  being  mistaken  for  a  clot, 
it  oi'ten  passes  away  unnoticed,  most  women  then  supposing  that  they  have 


568  PATHOLOGY    i>F    PREGNANCY. 

only  had  a  slight  postponement  of  their  menses,  followed  by  a  more  difficult 
and  abundant  flow  than  usual. 

At  a  more  advanced  stage,  the  symptoms  are  much  better  marked,  but 
still  vary  with  the  cause  of  the  abortion.  For  instance,  when  this  accident 
has  been  produced  under  the  influence  of  bad  health  in  the  mother,  or  of 
chronic  diseases,  or  those  causes  that  operate  slowly,  by  altering  the  genital 
organs,  or  the  ovum  and  its  membranes,  the  following  symptoms  are  ordi- 
narily observed,  namely:  shiverings  succeeded  by  heat,  anorexia,  nausea, 
thirst,  spontaneous  lassitude,  palpitations,  cold  extremities,  pallor,  sadness, 
depression  of  spirits,  tumefaction  and  lividity  of  the  eyelids,  want  of  bril- 
liancy in  the  eyes,  a  sense  of  sinking  at  the  epigastrium,  of  cold  about  the 
pubis,  of  weight  near  the  anus  and  vulva,  pain  in  the  loins,  vesical  tenesmus, 
frequent  ineffectual  desires  to  urinate,  and  a  weakness  and  flaccidity  of  the 
breasts,  from  which  a  serous  fluid  sometimes  exudes.  These  phenomena 
may  be  considered  as  the  precursors  of  an  abortion  ;  for,  when  they  have 
lasted  for  some  time,  the  pains  in  the  loins  become  more  and  more  acute, 
extend  round  to  the  hypogastrium,  and  are  renewed  at  short  intervals, 
finally  assuming  all  the  characteristics  of  the  regular  uterine  contractions. 
During  these  pains,  if  the  uterus  is  sufficiently  high  up  to  be  easily  dis- 
tinguished above  the  pubis,  it  will  be  felt  to  harden  sensibly,  whilst  at  the 
same  time  a  sanious  discharge  takes  place  from  the  vagina,  afterwards 
becoming  sanguinolent,  and  eventually  replaced  by  liquid  or  grumous 
blood.  If  the  woman  be  then  examined  per  vaginam,  the  neck  will  be 
found  partly  dilated,  the  dilatation  advancing  progressively  with  the  fre- 
quency of  the  pains ;  the  membi-anes  begin  to  protrude,  then  engage,  and 
ultimately  rupture;  the  waters  escape,  and  the  foetus  and  placenta  are  suc- 
cessively expelled.  Usually  in  those  cases  in  which  the  cause  has  operated 
slowly,  whether  dependent  on  diseases  of  the  mother  or  affections  of  the 
ovum,  the  foetus  dies  before  the  labor,  or  at  least  during  the  first  pains. 

When  the  abortion  is  a  consequence  of  the  occasional  violent  causes,  it 
usually  has  quite  another  course.  Thus,  in  some  instances,  the  expulsion 
of  the  ovum  closely  follows  the  accident ;  a  woman  slips  in  descending  a 
staircase,  and  falls  violently  on  her  seat;  when  she  rises,  her  clothes  are 
flooded  with  blood,  for  an  ovum  of  six  weeks  has  been  driven  out,  together 
« ith  a  large  quantity  of  fluid  blood.  This,  however,  is  more  apt  to  occur 
in  the  beginning  of  pregnancy;  for,  at  a  more  advanced  period,  some  inter- 
val always  elapses  between  the  accident  and  the  consequent  abortion.  The 
phenomena  then  observed  vary,  according  to  whether  the  cause  has  affected 
the  mother's  organs,  or  has  directly  influenced  the  foetus  itself. 

In  the  former  case,  the  mother  experiences,  at  the  time  of  the  accident,  a 
sharp  pain,  either  about  the  loins,  or  else  in  some  part  of  the  abdomen  ; 
after  the  lapse  of  a  few  days,  during  which  the  pain  has  diminished,  or  even 
entirely  ceased,  it  is  violently  renewed,  and  followed  almost  immediately 
by  uterine  pains  and  contractions,  a  slight  dilatation  of  the  neck,  some  dis- 
charges of  serosity  from  the  vagina,  at  first  reddish,  then  sanguinolent,  and 
lastly  pure  blood. 

Finally,  if  the  travail  continue,  the  foetus  is  expelled  as  usual,  and  often 
living. 


OF    ABORTION.  569 

'Hie  expulsion  is  almost  always  effected  very  slowly,  and  the  pi  ogress  of 
the  lahor  is  far  from  being  as  regular  as  at  term.  The  resistance  occasioned 
by  the  length  and  hardness  of  the  cervix  at  this  period  sufficiently  explain 
the  extreme  slowness  of  its  dilatation  ;  and  even  when  the  latter  is  sufficient, 
the  contractile  powers  of  the  uterus  are  yet  so  feeble  that  the  ovum  may 
remain  engaged  in  the  orifice  for  several  days,  and  even  project  into  the 
upper  part  of  the  vagina,  before  being  expelled  completely. 

When  the  cause  has  acted  directly  upon  the  foetus,  either  mechanically, 
as  by  a  violent  blow  or  concussion,  or  physiologically,  by  destroying  to  a 
greater  or  less  extent  its  vascular  connections  with  the  uterus,  the  subse- 
quent course  of  affairs  is  different ;  for  here  the  phenomena  which  announce 
the  death  of  the  product  of  conception  are  the  first  to  be  manifested.  After 
the  few  hours  necessary  to  dissipate  the  agitation  and  fears  caused  by  the 
commotion  she  has  experienced,  the  woman  feels  no  pain  nor  inconvenience ; 
everything  is  calm,  and  seems  to  resume  its  natural  order ;  but,  after  the 
lapse  of  a  few  days,  sometimes  only  eight  or  ten,  the  movements  of  the 
foetus,  which  had  up  to  this  time  maintained  their  usual  force  and  frequency, 
become  weaker,  are  separated  by  longer  intervals,  and  finally  become 
imperceptible.  From  this  moment,  the  uncomfortable  sensations  and  diges- 
tive disorders,  which  had  annoyed  the  patient  from  the  outset  of  pregnancy, 
disappear  as  though  by  magic ;  the  swelling  of  the  breasts  and  prickling 
sensations  which  had  affected  them,  also  diminish  or  cease  entirely.  A 
miscarriage  is  then  inevitable,  for  the  ovum  is  a  foreign  body  in  the  uterine 
cavity,  and  soon  irritates  the  walls  of  the  organ  by  its  presence ;  the  latter 
contracts,  and  the  expulsion  is  generally  effected  about  eight  to  nine  days 
after  the  accident.  In  this  case,  the  process  advances  in  a  more  regular 
manner,  because  the  womb  has  had  time  to  prepare  itself  for  the  act. 
However,  this  term  is  not  uniform,  it  being  not  at  all  uncommon  for  the 
dead  foetus  to  remain  much  longer  in  the  womb  :  two  or  three  weeks,  or  a 
month,  for  example.  I  saw  a  woman  at  the  Clinique,  in  whom  the  child's 
death  was  clearly  ascertained,  though  she  did  not  abort  until  six  weeks 
afterwards.  Cases  are  also  recorded  of  the  embryo  remaining  in  the  womb 
until  the  ninth  month. 

The  development  of  the  contractions  is  solicited  by  the  derangement 
which  this  condition  of  death  gradually  produces  in  the  placental  circu- 
lation; indeed,  the  quantity  of  blood  arriving  in  the  placenta  often  dimin- 
ishes by  degrees,  and  ultimately  becomes  almost  nul;  but  this  is  not  always 
the  case,  since,  in  some  instances,  the  circulation  continues,  and  the  placenta 
enlarges, — attains  even  to  double  the  volume  of  that  at  term,  and  after  its 
expulsion  exhibits  the  same  degree  of  integrity.  Lastly,  in  other  cases,  says 
M.  Guillemot,  the  placenta  retains  its  vitality  and  grows;  but,  at  the  same 
time,  assumes  unusual  forms,  and  a  singular  structure,  exhibiting  a  cavity 
in  which  remains  of  the  foetus  are  hardly  to  be  found. 

Where  a  long  time  thus  ensues  between  the  period  of  the  child's  death 
and  that  of  its  expulsion,  there  is,  in  general,  less  danger  from  hemorrhage 
than  if  the  premature  labor  had  taken  place  immediately.  In  these  abor- 
tions, less  blood  is  usually  lost  than  in  the  labors  which  come  on  naturally, 
after  tin  most  favorable  gestations;  which  is  probably  owing  to  the  fact 


570  PATHOLOGY    OF    PREGNANCY. 

that  the  child's  death  diminishes  the  activity  of  the  uterine  circulation, 
especially  that  of  the  utero-placental  vessels,  which  must  then  become 
obliterated  in  a  great  measure,  and  consequently  can  furnish  but  little 
blood  at  the  time  when  the  placenta  is  separated. 

We  have  seen  (page  558)  that  the  general  phenomena  experienced  by 
the  mother  after  the  death  of  the  foetus  are  very  singular  in  these  cases,  but 
abortion  does  not  always  follow  immediately,  a  variable  interval,  sometimes 
a  long  one,  intervening  before  labor  begins.  The  child  born  under  these 
circumstances  has  a  peculiar  macerated  appearance,  but  no  evidence  of 
putrefaction. 

But  it  happens  otherwise  when,  the  foetus  being  dead,  the  membranes  are 
ruptured,  and  the  expulsion  is  delayed;  for  then  a  rapid  putrefaction  sets 
in,  as  a  consequence  of  the  contact  of  the  child  with  the  external  air.  A 
high  fever,  characterized  by  the  symptoms  of  a  veritable  infection,  develops 
itself;  a  dark  fetid  liquid  oozes  from  the  genital  parts,  mixed  with  shreds, 
in  a  state  of  putrefaction ;  and  if  the  uterine  contractions  do  not  speedily 
relieve  the  organism  from  this  source  of  infection,  the  patient  may  rapidly 
succumb  under  its  deleterious  influence.  Finally,  when  the  abortion  is 
brought  on  by  the  existence  of  two  children,  the  twins  are  nearly  always 
expelled  simultaneously;  although  we  have  occasionally  known  the  women 
to  abort  of  one  child  in  a  multiple  pregnancy,  whilst  the  other  continued 
to  grow. 

Hemorrhage  is  one  of  the  most  common  symptoms.  It  may  precede, 
accompany,  or  follow  the  expulsion  of  the  foetus,  and  is  of  such  frequent 
occurrence  that  most  authors  make  it  the  principal  disordei  In  some 
cases  it  is  certainly  the  cause  of  the  abortion,  though  often  merely  a  con- 
sequence. Sometimes,  indeed,  the  miscarriage  is  accompanied  with  but 
slight  hemorrhage.  The  latter  circumstance  is,  however,  rare,  especially  in 
the  false  labors  that  take  place  before  the  end  of  the  fourth  month ;  because 
a  more  or  less  abundant  discharge  of  blood  nearly  always  show7s  itself  during 
the  first  expulsive  pains,  and  persists  until  the  uterus  is  completely  emptied; 
but,  as  we  all  know,  nothing  of  this  kind  is  observed  in  labor  at  term.  M. 
Jacquemier  has  happily  explained  the  difference  between  the  two  in  the 
following  manner:  He  states  that,  towards  the  end  of  gestation,  the  placenta 
spreads  out  from  the  centre  towards  the  circumference,  in  order  to  conform 
itself  to  the  uterine  enlargement  at  its  greater  extent;  and  this  is  accom- 
plished in  such  a  way  that  its  different  lobes,  by  separating  from  one  another, 
have  a  considerable  space  left  between  them.1  From  this  it  follows,  that, 
within  certain  limits,  the  uterine  contractions  have  no  tendency  to  detach 
it;  for  the  placenta  accommodates  itself  wonderfully  to  the  retraction  of  the 
organ  until  it  reaches  its  own  proper  limits;  and  even  then  its  great  flexibility 
permits  a  further  reduction,  so  as  to  follow  the  uterus  as  it  becomes  less, 
before  the  detachment  commences,  and  this  latter  phenomenon  only  takes 
place  when  the  entire  foetus  is  nearly  expelled.     But,  prior  to  the  fourth 

1  To  convince  one's  self  of  the  truth  of  this  fact,  it  is  only  necessary  to  see  the  pla- 
centa  still  adherent  to  a  uterus  which  has  been  developed  but  is  not  yet  retracted,  or 
even  the  uterine  surface  this  mass  occupied ;  for  the  latter  is  nearly  one-third  larger 
than  the  surface  of  the  placenta  which  covered  it.      [Jacquemkr.) 


OP   ABORTION.  571 

month,  the  after-birth  is  far  from  offering  the  same  conditions  ;  since  the 
thickness  of  the  uteroplacental  decidua  and  the  large  amount  of  plastic 
matter  interposed  between  the  lobes  at  that  time,  confer  upon  it  a  much 
greater  density;  and  therefore  it  can  only  yield  within  very  narrow  limits, 
either  in  the  way  of  extension  or  retraction  towards  its  centre.  Hence,  the 
facility  of  its  separation  during  the  early  contractions,  the  rupture  of  a 
certain  number  of  vessels,  and  the  incessant  hemorrhage  throughout  the 
whole  duration  of  the  labor. 

ARTICLE    III. 

DIAGNOSIS. 

Judging  from  the  numerous  signs  just  given,  the  diagnosis  of  an  abortion 
ought  to  be  very  easy ;  but,  unfortunately,  these  signs  are  not  very  clearly 
marked  until  the  accident  is  inevitable,  and  consequently,  when  it  is  a 
matter  of  indifference  to  the  patient  whether  the  physician  makes  oui.  a 
clear  diagnosis  or  not. 

It  is,  therefore,  in  the  beginning  of  such  symptoms,  especially,  that  we 
should  endeavor  to  recognize  their  true  nature,  because  then  only  can  our 
art  succeed  in  arresting  their  progress ;  but  this  is  exceedingly  difficult. 

The  diagnosis  of  abortion  involves  the  solution  of  several  questions.  Is 
the  woman  pregnant  ?  And,  supposing  the  pregnancy  to  be  determined, 
are  the  symptoms  those  of  a  simple  uterine  congestion,  or  of  a  commencing 
abortion  ?     Lastly,  is  the  abortion  inevitable  ? 

1.  Is  the  Woman  Pregnant? — This  first  question  is  quite  readily  resolved 
after  the  fourth  month  of  gestation,  though  before  that  period  it  is  almost 
always  unanswerable.  All  practitioners  of  obstetrical  experience  are  aware 
of  the  difficulties  which  often  involve  it.  Thus,  a  woman  in  good  health 
has  her  courses  suddenly  suppressed  for  several  months  without  *vny  appre- 
ciable cause,  the  breasts  swell,  and  the  body  increases  in  size :  in  a  word, 
she  experiences  several  of  the  phenomena  properly  regarded  as  rational 
signs  of  pregnancy ;  then,  all  at  once,  at  the  return  of  the  third  or  fourth 
menstrual  period,  some  symptoms  of  congestion  of  the  uterus  appear,  last 
for  several  days,  and  are  soon  followed  by  a  slight  flow  of  blood.  How, 
then,  shall  we  determine  whether  the  pains  felt  by  the  patient,  and  the  dis- 
charge of  blood  from  the  vulva,  are  owing  to  a  return  of  the  interrupted 
menses,  or  to  an  approaching  abortion  ?  The  pains  attendant  on  difficult 
menstruation,  especially  after  a  suspension  of  several  months,  resemble 
greatly,  both  in  situation  and  intermittence,  those  of  abortion.  According 
to  Madame  Lachapelle,  in  abortion  the  uterine  orifice  is  open,  the  hemor- 
rhage precedes  the  pains,  and  the  latter  persist  notwithstanding  the  abun- 
dance of  the  discharge  ;  whilst  in  difficult  menstruation  the  orifice  is  closed, 
the  pains  are  felt  before  the  hemorrhage  appears,  and  they  diminish  or  even 
cease  entirely  when  the  discharge  is  well  established.  The  contrary,  how- 
ever, not  unfrequently  occurs. 

Doubtless  a  strict  investigation  of  the  circumstances  which  accompanied 
and  followed  the  suppression  of  the  menses,  and  an  examination  of  the 
uterus,  might  lead  to  an  opinion  as  to  the  probable  state  of  the  case ;  but 


672  PATHOLOGY  OF  PREGNANCY. 

what  experienced  physician  does  not  know  how  deceptive  are  all  these 
rational  signs,  when  we  take  into  consideration  the  tendency  to  exaggerations 
of  the  females,  who  so  readily  believe  what  they  wish  or  what  they  fear,  as 
also  how  nearly  the  congestion,  which  precedes  and  accompanies  the  sus- 
pended menstruation,  places  the  uterus  in  the  same  physical  conditions  as 
in  a  commencing  pregnancy? 

Does  the  blood  escape  from  the  genital  parts  as  a  clot?  It  has  been 
hoped  that  the  shape  of  the  latter  might  furnish  a  reliable  sign. 

It  has  been  stated  that  the  clot  driven  from  the  unimpregnated  womb 
exhibits  a  triangular  form,  corresponding  to  that  of  the  cavity  where  the 
blood  coagulated,  which  never  happens  when  a  product  of  conception  is 
present ;  but  this  may  fail,  as  the  clot  is  mostly  changed  in  its  shape  by 
traversing  the  neck  ;  and,  on  the  other  hand,  in  abortion,  the  blood  may 
collect  and  coagulate  in  the  vagina,  and  the  coagulum  exhibit  the  indi- 
cated character. 

But,  if  the  coagulum  be  still  in  the  cervix  uteri,  and  supposing  the  finger 
is  able  to  reach  this  point,  how  can  we  distinguish  whether  the  foreign  body 
felt  there  is  a  clot  or  ovum  ?  For  this  purpose,  Holl  has  laid  down  the  fol- 
lowing signs :  If  the  finger  introduced  into  the  orifice  perceives  the  mass  to 
become  tense  during  the  contraction,  to  augment  in  volume  and  advance 
towards  the  vulva,  it  is  an  ovum  engaged  in  the  os  uteri ;  and  if  it  were  a 
clot,  it  might  be  recognized  by  its  fibrinous  structure ;  besides,  during  the 
pain,  its  exterior  surface  would  not  be  more  tense,  nor  more  smooth,  and  it 
would  not  appear  forced  down,  but  rather  compressed ;  finally,  as  the  ovum 
resembles  a  soft  bladder,  its  inferior  extremity  is  rather  rounded  than 
pointed,  while  the  coagulated  mass  is  more  resistant  and  solid,  is  less  com- 
pressible, and  has,  in  general,  the  form  of  a  cone,  the  enlarged  extremity  of 
which  is  above  and  the  apex  below. 

Finally,  if  we  should  then  attempt  to  move  the  uterus  in  its  totality  by 
pressing  on  this  mass,  it  might  be  easily  effected  if  there  were  a  clot  con- 
cerned, whilst  the  parietes  of  the  ovum  would  yield,  and  would  not  transmit 
the  motion  to  the  organ  which  envelops  it,  and  with  which  it  is  then  but 
feebly  adherent. 

The  question  is  therefore  by  no  means  simple,  yet  it  is  important  to  know 
whether  pregnancy  really  exists;  for  as  the  appearance  of  the  menses  is 
then  of  very  rare  occurrence,  especially  when  they  are  absent  in  the  early 
months,  a  flow  of  blood  should  be  treated  as  a  serious  accident,  which,  on 
the  contrary,  would  be  promoted,  if  attributable  to  a  return  of  the  courses. 
Notwithstanding  these  uncertainties,  there  may  be  a  union  of  circumstances 
Buch  as  to  allow  of  at  least  a  probable  diagnosis.  Thus,  if  a  woman,  who 
has  been  habitually  regular,  finds  her  catamenia  to  stop  suddenly  and  unac- 
countably; if  this  suppression  is  followed  by  other  rational  signs  of  preg- 
nancy; if  the  pains  continue  notwithstanding  the  discharge  of  blood;  if 
they  appear  as  an  effect  of  any  violence  whatsoever,  or  if  they  present  any 
thing  unusual  as  respects  either  intensity  or  duration,  it  may  be  concluded 
that  abortion  is  imminent.  The  diagnosis  becomes  more  certain  if  the  blood 
Hows  more  profusely  than  in  ordinary  menstruation,  if  it  is  accompanied 
with    sharper    pains    in    the    hypogastrium    than    is    usual,    if    coagula   are 


OF    ABORTION.  '"'' 


expelled,  and  if  the  orifice  is  sufficiently  dilated  to  admit  the  extremity  of 

the  finger.  .      , 

2  Pregnancy  existing,  may  the  symptoms  be  attributed  to  simple  con- 
gestion of  the  uterus,  or  should  they  be  regarded  as  the  first  tokens  ot  a 
Threatened  abortion?  Though  it  is  very  difficult  to  decide  this  question 
within  the  first  three  or  four  months,  and  at  the  beginning  of  the  accident, 
its  solution  is  happily  of  little  importance  as  regards  the  treatment,  the 
measures  indicated  by  simple  congestion  being  equally  applicable  to  the 
prevention  of  miscarriage. 

When  symptoms,  which  in  all  appearance  were  due  to  simple  congestion, 
have  yielded  to  proper  treatment,  the  physician  is  often  required  to  answer 
a  question  whose  rigorous  solution  is  always  impossible :  namely,  the  abdom- 
inal and  lumbar  pains  being  allayed,  and  all  the  other  alarming  symptoms 
removed,  is  the  patient  therefore  out  of  danger  of  miscarriage?  In  the 
majority  of  cases  we  can  tell  nothing  about  it,  for  it  is  impossible  to  know 
whether  the  congestion  has  been  arrested  in  time  to  prevent  a  rupture  of 
blood-vessels,  and  an  effusion  between  the  placenta  and  uterus,  or  whether 
the  separation  of  the  placenta  is  extensive  enough  to  have  destroyed  the 
foetus  immediately ;  even  supposing  the  child  to  be  still  living,  we  canno 
ascertain  the  degree  of  separation  of  the  placenta,  nor  foresee  the  effect 
which  a  partial  destruction  of  its  maternal  attachments  may  have  upon  the 
foetus.  Very  frequently,  indeed,  the  latter,  by  being  cut  off  from  a  con- 
siderable part  of  its  means  of  respiration,  is  placed  in  the  condition  of  an 
adult  whose  lungs  are  in  great  measure  destroyed,  and  whose  respiration 
and  nutrition  being  insufficient,  gradually  wastes  away,  so  the  child  often 
does  not  perish  until  after  the  lapse  of  eight  days,  two  weeks,  and  frequently 
even  not  until  the  next  menstrual  period  ;  this,  too,  without  the  appearance 
of  any  new  symptoms  to  explain  its  unlooked-for  death.  The  physician 
cannot  therefore  be  too  reserved  in  his  diagnosis,  as  regards  the  possible 
consequences  of  such  accidents. 

3.  Finally,  supposing  the  abortion  begun,  can  we  hope  to  arrest  the 
symptoms?  The  intensity  of  the  pains,  their  constant  direction  from  the 
umbilicus  towards  the  coccyx,  the  previous  duration  of  the  discharge  and 
the  amount  of  blood  already  lost,  softening  and  dilatation  of  a  most  the 
entire  neck,  and  even  of  the  internal  orifice,  and  projection  of  the  mem- 
branes during  the  contraction,  doubtless  indicate  a  very  unfavorable  prog- 
nosis, though  they  should  not  destroy  all  hope.  All  these  symptoms  con- 
jointly have  in  fact  been  known  to  yield  to  appropriate  treatment,  every- 
thing  to  resume  the  natural  state,  and  the  pregnancy  to  go  on  as  usual. 
Some  authors  even  state  that  the  rupture  of  the  membranes  and  discharge 
of  the  amniotic  fluid  does  not  render  abortion  inevitable,  lhis  Last  asser- 
tion, however,  seems  to  me  to  be  at  least  very  contestable,  lor  it  ,s  infinitely 
probable,  not  to  say  certain,  that  in  the  cases  alluded  to  there  has  been  a 
mistake  in  reference  to  the  true  origin  of  the  waters  lost  by  the  patient.  It 
appears  to  me  that  a  rupture  of  the  ovum  must  inevitably  give  rise  to 
abortion;  and  Desormeaux  has  certainly  confounded  cases  of  hydrorrhea 
with  the  true  discharge  of  the  amniotic  fluid.  _  _ 

A  young  lady,  who  had  already  been  so  unfortunate  as  to  miscarry  in  her 


574  PATHOLOGY  OF  PREGNANCY. 

first  pregnancy,  to  be  delivered  of  a  dead  child  in  the  second,  and  finally 
to  have  lost  a  little  girl  of  six  months,  had  advanced  three  months  and  a 
half  in  a  fourth  pregnancy.  After  returning  from  mass,  in  a  church  very 
near  her  dwelling,  there  was  a  sudden  discharge  of  flnid  from  the  genital 
organs,  to  an  amount  estimated  by  the  patient  at  about  a  tumblerful.  Ou 
first  seeing  her,  I  thought  abortion  inevitable.  Then,  upon  a  careful  exami- 
nation of  the  uterus,  it  seemed  to  me,  that,  notwithstanding  the  loss  which 
had  occurred,  the  organ  presented  its  usual  size,  a  certain  elasticity,  a  pecu- 
liar suppleness  showing  that  some  fluid  must  still  remain  within  the  amni- 
otic cavity  ;  there  was  nothing  peculiar  in  the  state  of  the  cervix  ;  no  flow 
of  blood  ;  neither  was  there  pain  before,  during,  or  after  the  discharge  of 
water.  In  acquainting  the  patient  with  the  fears  which  I  entertained,  I 
also  assured  her  that  all  hope  was  not  lost,  and  that  the  circumstances  just 
mentioned  presented  collectively  features  which  do  not  usually  appertain  to 
ruptures  of  the  ovum  itself.  Absolute  quiet,  a  small  bleeding  from  the 
arm,  opiate  enemata,  and  hand-baths,  to  be  repeated  morning  and  evening, 
were  directed.  No  new  symptoms  supervened,  and  the  development  of  the 
uterus  continued.  For  the  first  two  days,  there  was  still  a  very  small  dis- 
charge of  water.  At  four  months  and  a  half,  and  also  without  appreciable 
cause,  there  was  a  sudden  escape  of  five  or  six  spoonfuls  of  a  fluid  similar 
to  the  preceding.  After  this,  nothing  of  the  kind  occurred  until  the  end  of 
her  pregnancy,  which  terminated  very  happily.     (See  Hydrorrhea.) 

Abortion  is  really  inevitable  only  when  the  foetus  has  ceased  to  live,  or 
when  the  separation  of  the  placenta  and  the  rupture  of  the  utero-placental 
vessels  are  so  extensive  that  the  remaining  utero-placental  attachments  are 
unequal  to  the  support  of  the  foetal  respiration. 

In  order  to  estimate  the  probable  degree  of  disturbance  of  the  utero- 
placental relations  which  has  taken  place,  much  more  regard  must  be  had 
to  the  amount  of  the  discharge  than  to  its  duration.  A  simple  exudation, 
or  a  moderate  flow  of  blood,  may  continue  for  several  days  or  weeks,  since 
it  may  originate  in  the  rupture  of  very  few  vessels ;  I  have  known  it  to  last 
for  six  weeks  and  two  months,  without  compromising  the  pregnancy ;  but 
that  the  patient  should  lose  a  considerable  amount  of  fluid  or  coagulated 
blood  in  a  short  time,  the  placenta  must  be  separated  to  a  considerable  extent, 
and  abortion  almost  necessarily  ensues. 

There  is  still  another  peculiarity  not  mentioned  by  authors,  which  appears 
to  me  of  importance,  inasmuch  as  it  cuts  off  almost  all  hope  of  arresting 
the  progress  of  the  symptoms:  I  allude  to  a  particular  form  of  the  neck. 
When  the  patient  has  been  for  a  short  time  only  pregnant,  we  know  that  it 
is  always  easy  to  distinguish  the  neck  of  the  uterus  from  its  body;  in  the 
irreat  majority  of  cases,  we  may  even  feel  the  angle  which  separates  them. 
Now,  when  the  contractions  have  lasted  for  a  certain  time,  they  have  grad- 
ually dilated  the  internal  orifice;  the  cavity  of  the  neck  has  become  con- 
founded with  that  of  the  body,  and  when  the  finger  in  the  vagina  is  passed 
over  the  entire  lower  Begment  of  the  uterus,  the  neck  can  no  longer  be  dis- 
tinguished from  it;  a  well-defined  limit  between  them  is  no  more  to  be 
detected,  and  all  that  belongs  to  the  neck  of  the  womb  has  the  shape  of  a 
peai,  the  larger  part  being  continuous  with  the  body  of  the  organ,  and  the 


OF    ABORTION.  575 

lower  extremity  corresponding  with  the  external  orifice.  "Whenever  I  have 
met  with  this  condition  of  things,  abortion  has  taken  place.  "  The  vagina 
itself,"  Dr.  Coffin  remarks,  "is  so  far  affected,  that  its  upper  extremity 
becomes  rounded,  the  rugse  are  effaced,  and  the  finger  meets  everywhere  a 
smooth  and  regular  surface  like  that  of  a  polished  vase." 

It  is  impossible  to  ascertain  certainly  in  the  early  months,  whether  the 
foetus  be  living  or  dead.  I  must,  however,  mention  a  peculiarity  which  in 
my  estimation  is  of  great  value  in  reference  to  this  question  :  namely,  the 
sudden  cessation  of  the  vomitings,  salivation,  or  any  other  sympathetic 
functional  disorder  of  pregnancy.  When,  after  an  accident,  vomiting  and 
salivation  cease,  there  is  cause  to  fear  that  the  child  is  dead,  the  persistence 
of  these  discomforts  being  on  the  contrary  a  favorable  sign.  Happily,  though 
the  uncertainty  upon  this  point  makes  an  exact  prognosis  impossible,  it  in 
no  wise  affects  the  treatment.  Whenever,  indeed,  a  collective  examination 
of  the  general  and  local  symptoms  leads  to  the  supposition  that  the  child 
\s  living,  and  that  we  may  hope  to  arrest  the  progress  of  the  accident,  we 
should  act  as  though  we  were  certain. 

We  see,  therefore,  that  in  the  first  third  of  gestation  the  diagnosis,  at  the 
best,  can  be  only  probable. 

At  a  more  advanced  stage  of  gestation,  the  diagnosis  is  much  more  cer- 
tain. First,  because  we  can  then  generally  ascertain  the  development  of 
the  uterus  without  difficulty ;  then,  again,  pains  are  more  energetic  :  the 
blood  flows  in  greater  abundance,  and  the  dilatation  of  the  os  uteri  is  more 
easily  detected ;  but  it  becomes  still  more  certain  when  the  death  of  the 
foetus  can  be  verified  in  a  positive  manner.  (See  Signs  of  the  Death  of  the 
Fcetus,  page  558.) 

ARTICLE  IV. 

DELIVERY   OF   THE   AFTER-BIRTH. 

The  spontaneous  expulsion  or  the  extraction  of  the  placenta  presents 
very  different  phenomena  according  to  the  period  when  the  abortion  takes 
place ;  and,  in  this  respect,  it  is  highly  important  to  distinguish  the  accident 
in  the  first  two  months  from  that  of  the  third  and  fourth,  as  also  from  that 
of  the  fifth  and  sixth ;  for  the  ovum  is  usually  expelled  entire  iu  the  first 
and  second  months,  but  in  the  two  latter  the  expulsion  of  the  placenta  is 
accomplished  nearly  in  the  same  way  as  at  term.  But  in  the  third  and 
fourth  months  it  is  altogether  different,  because  the  placenta,  which  is 
already  voluminous,  has  contracted  at  this  period  numerous  and  very  inti- 
mate adhesions  with  the  womb,  which  has  not  as  yet  acquired  all  the  con- 
tractility of  tissue  that  it  possesses  at  term;  consequently  the  premature 
contractions,  although  sufficiently  energetic  to  rupture  the  ovum,  are  not 
adequate  to  the  destruction  of  the  utero-placental  adhesions.  Hence,  under 
the  influence  of  such  contractions,  the  amniotic  sac,  being  pressed  on  all 
sides,  yields  near  the  neck,  the  waters  escape,  the  little  foetus  is  expelled, 
And  the  very  delicate  umbilical  cord  breaks  easily;  at  the  same  time  a  cer- 
tain quantity  of  liquid  or  coagulated  blood  is  poured  out,  and  very  often  the 
small  fcetus  is  lost  in  the  midst  of  the  coagula  that  accompany  its  discharge, 
Then  the  uterus,  being  partially  evacuated,  retracts,  the  neck  closes  up 


576  PATHOLOGY  OF  PREGNANCY. 

and  the  symptoms  disappear;  nevertheless, the  placenta  and  membranes  are 
still  undelivered,  and  may  remain  in  the  womb  for  eight,  ten,  or  twelve 
days,  or  even  longer.  Dr.  Advena,  of  Labischin,  reports  an  instance  where 
the  after-birth  was  not  expelled  till  three  months  subsequent  to  the  abortion 
this  latter  having  occurred  at  the  fifth  month  of  pregnancy.  {Journal  de 
( 'hirurgie,  Aug.  1843.) 

The  complete  closure  of  the  neck  evidently  makes  the  introduction  of  the 
finger  impossible,  so  that  every  attempt  made  for  this  purpose  would  prove 
fruitless.  Ergot  may,  indeed,  be  administered  with  the  object  of  exciting 
contractions,  though  I  have  never  seen  it  have  any  good  effects  when  given 
under  these  circumstances.  To  wait,  at  the  same  time  watching  carefully, 
is  all  that  can  be  done. 

The  symptoms  which  may  then  result  from  retention  of  the  placenta  are 
very  variable,  and  should  be  carefully  studied. 

1.  Very  frequently,  nothing  at  all  unusual  is  observed  for  a  few  days  fol- 
lowing the  miscarriage.  The  general  health  is  good  ;  the  patient,  believing 
herself  entirely  cured,  gradually  resumes  her  ordinary  occupations,  when  ali 
at  once,  and  without  any  known  cause,  some  intermittent  pains  are  felt  in 
the  hypogastrium,  and  a  little  blood  escapes  from  the  vulva.  The  woman 
often  neglects  these  primary  symptoms,  but  they  persist  and  augment  in 
intensity,  thereby  constraining  her  attention  to  them;  for  the  placenta  has 
become  a  foreign  body  in  the  womb,  and,  irritating  the  uterine  wralls  by  its 
presence,  excites  their  contractions;  these  break  up  the  utero-placental 
adhesions,  and  the  after-birth  is  almost  free  in  the  uterine  cavity.  This 
separation  is  always  accompanied  by  hemorrhage,  which  is  at  times  verv 
abundant,  because  the  os  uteri  dilates  with  so  much  difficulty,  to  permit  the 
foreign  body  to  escape,  that  the  latter,  by  remaining  in  the  womb,  encourages 
a  hemorrhage  by  irritating  the  organ  and  preventing  the  complete  contrac- 
tion of  its  walls ;  insomuch  that,  if  art  does  not  seasonably  interpose,  life 
itself  may  lie  endangered.  What  is  still  worse,  if  the  physician  was  not  pres- 
ent at  the  time  of  the  miscarriage,  and  carefully  examined  all  the  clots  him- 
self, tin1  attendants  will  tell  him  that  the  after-birth  and  the  child  were 
expelled  together,  and  he  may  possibly  overlook  the  cause  of  the  accident. 
Consequently,  the  accoucheur  should  rely  exclusively  on  his  own  personal 
examination,  lie  must  absolutely  touch  the  female,  when  he  will  usually 
find  the  os  uteri  to  be  partially  dilated,  and  a  portion  of  Lhe  placenta  hang- 
ing in  its  orifice.  It  then  is  only  necessary  to  seize  this  portion  with  the  two 
fingers,  for  its  extraction  is,  in  general,  quite  easy.  In  case  of  necessity, 
Levret's  abortion-forceps,  Duges'  placenta-crotchet,  or  Pajot's  curette,  might 
be  used  for  this  purpose. 

[It  has  always  been  my  practice  to  remove  the  whole  ovum — foetus,  placenta,  mem- 
branes,  ami  all — before  leaving  a  patient  who  is  aborting,  provided,  of  course,  the 
uterine  canal  was  sufficiently  patulous  ami  no  injurious  force  was  required  to  accomplish 
my  object.  To  remove  the  placenta  and  membranes,  1  have  used  preferably  my  fingers, 
aided  by  pressure  on  the  abdominal  walls,  and  when  I  failed  with  this  method,  I  have 
always  succeeded  in  detaching  the  secundines  with  a  large,  blunt  curette,  and  in  re- 
moving them  with  the  fingers  or  a  long,  broad  forceps.  My  reason  for  this  has  been 
that  no  woman  has  seemed  to  me  free  from  the  danger  of  hemorrhage  or  sepsis,  so  long 
as  a  portion  of  the  secundines  remained  in  the  uterus,  and  I  have  never  had  occasion 
to  regret  following  this  practice.  (SeeAmer.  Jour,  of  Obstetrics,  Feb.,  1881.)— P.  F.  M.l 


OF    ABORTION.  .",77 

Sometimes  the  adhesions  of  the  placenta  are  so  numerous  that  it  is  im- 
possible to  destroy  them.  It  is  then  possible,  by  strong  pressure  upon  the 
hypogastrium,  to  depress  the  womb,  so  that  the  forefinger  of  the  other  hand 
can  be  passed  into  its  cavity,  and  glided  between  the  placenta  and  the  uterine 

walls.  If  this  does  not  succeed,  the  tampon  must  be  resorted  to,  and  the  ergol 
administered  at  once  ;  conjoint  use  of  these  measures  rarely  tails  to  arrest  the 
hemorrhage,  and  bring  on  sufficient  contraction  to  expel  the  secundines.1 

Such  are  the  measures  whenever  the  hemorrhage  becomes  dangerous 
either  by  its  duration  or  abundance.  When,  however,  it  is  arrested, espe- 
cially when  the  placenta  is  partially  engaged  beneath  the  orifice,  and  seems 
to  prevent,  by  its  presence  there,  further  discharge,  we  should  wait,  and  be 
very  careful  how  we  attempt  to  extract  it  immediately.  The  engagement 
of  the  placenta  in  the  cavity  of  the  neck  maintains  in  the  latter  a  degree 
of  dilatation  likely  to  facilitate  its  complete  expulsion,  and  besides  exciting, 
as  a  foreign  body,  the  sensibility  of  that  part,  also  excites,  or  at  least  keeps 
up,  the  contractions  of  the  fundus  of  the  womb.  Tractions  upon  the 
engaged  portions  might  tear  the  placental  mass  at  the  point  of  constriction 
by  the  retracted  internal  orifice.  Now  immediately  after  this  partial  ex- 
traction, the  neck  would  resume  its  former  condition,  the  internal  orifice 
would  close  more  or  less  completely,  and  render  impossible  the  removal  of 
the  portion  of  placenta  remaining  in  the  cavity  of  the  body  of  the  uterus. 

2.  Sometimes  the  placenta  remains  in  the  uterine  cavity  after  having  been 
separated  wholly,  or  in  part,  and  soon  undergoes  decomposition,  just  as 
though  it  were  exposed  to  the  air ;  the  lochia  become  fetid ;  the  uterine 
walls,  being  in  contact  with  the  substances  in  course  of  putrefaction,  absorb 
a  portion  thereof,  and,  as  a  consequence,  fever  is  developed,  together  with 
all  the  symptoms  of  a  putrid  infection.  In  these  cases,  we  should  evidently 
relieve  the  womb  from  those  foul  materials  that  infect  the  whole  economy ; 
unfortunately,  the  neck  of  the  uterus  is  completely  closed,  and  an  intro- 
duction of  the  finger  thereby  rendered  impossible.  Often  it  is  exceedingly 
difficult  to  make  the  extremity  of  a  canula  enter  for  the  purpose  of  throw- 
ing detergent  injections  into  the  uterine  cavity,  and  we  are  then  compelled 
to  await  the  complete  expulsion  of  the  sanious  matters  resulting  from  the 
,  decomposition.  In  such  cases,  M.  Velpeau  speaks  favorably  of  the  use  of 
ergot.  This,  indeed,  is  a  remedy  that  might  be  used,  but  from  which, 
nevertheless,  we  should  not  expect  too  much.2 

A  lady,  thirty-five  years  of  age,  whom  I  suspected  to  be  pregnant,  although 
she  would  not  believe  it,  felt  a  discharge  from  the  parts  after  a  suspension 
yf  the  menses  for  two  months  and  a  half,  which  she  at  first  mistook  for  a 
return  of  her  courses,  but  which,  after  riding  out  in  a  carriage,  was  suddenly 

'Full  doses  of  the  fluid  extract  of  ergot,  or  subcutaneous  injection  of  ergotine, 
should  be  given.  It  is  strongly  advised  to  soak  the  pledgets  of  col  ion,  wool,  the 
sponge,  or  other  material  used  for  plugging  the  vagina,  with  glycerines  or  carbolic 
acid  and  water  (2ss.  to  ()j.).  The  tampon  should  not  be  allowed  to  remain  longer  than 
from  6  to  12  hours  without  renewal. 

2  If,  after  employing  the  tampon  for  twenty-four  hours,  the  cervix  remains  closed,  a 
tupelo  tent  should  be  resorted  to,  never  a  sponge,  on  account  of  the  danger  of  septic 
infection. 
37 


OlS  PATHOLOGY    OF   PREGNANCY. 

converted  into  a  profuse  flooding.  Having  been  summoned  immediately,  I 
found  the  os  uteri  slightly  dilated,  and  I  forthwith  employed  various  mea- 
sures adapted  to  the  arrest  of  the  discharge,  and  among  others  the  ergot. 
The  hemorrhage  gradually  diminished,  and  at  ten  o'clock  p.  M.  (six  hours 
subsequent  to  the  invasion  of  the  symptoms)  it  had  entirely  ceased.  During 
the  first  five  days  the  patient  did  very  well,  but  on  the  sixth  I  thought  I 
detected  a  slight  odor  in  the  lochia,  and  at  three  o'clock  in  the  afternoon  a 
violent  chill  came  on,  which  lasted  an  hour.  From  this  moment  all  the 
phenomena  of  absorption  were  manifested.  I  immediately  administered 
forty  grains  of  the  ergot,  but  without  effect,  for  nothing  came  away ;  and 
notwithstanding  the  enlightened  efforts  of  Messrs.  Chomel  and  Moreau,  who 
were  several  times  called  in  consultation,  this  unfortunate  lady  died  on  the 
tenth  day  following  the  appearance  of  the  first  symptoms.  At  the  post- 
mortem examination  we  found  the  uterine  tissue  softened,  and  its  cavity  filled 
by  the  putrefied  and  still  adherent  placenta,  which  we  could  not  separate 
without  tearing. 

3.  It  may  further  happen  that  the  placenta,  maintaining  its  vascular 
adhesion  with  the  internal  surface  of  the  organ,  continues  to  be  developed 
after  the  child's  death,  the  cord  and  foetus  become  atrophied,  and  then  com- 
pletely destroyed  ;  or,  indeed,  the  ovum  may  rupture,  and  the  little  product 
escape,  leaving  the  membranes  behind.  These  envelopes  may  undergo 
various  modifications,  but  the  most  common  is  the  morbid  product  known  as 
a  fleshy  mole.  It  has  been  generally  conceded,  since  the  researches  of  M. 
Velpeau  on  the  subject,  that  moles  which  are  expelled  from  the  uterine 
cavity  are  merely  the  remains  of  an  altered  product  of  conception. 

4.  Lastly,  there  is  yet  another  mode  of  termination,  admitted  by  Nsegele, 
Osiander,  &c.  I  allude  to  the  absorption  of  the  placenta  retained  in  the 
cavity  of  the  womb ;  for  although  such  an  absorption  has  been  observed 
even  after  delivery  at  term,  yet  most  of  the  reported  cases  refer  especially 
to  miscarriages.     (See  Delivery  of  the  After-birth.} 

ARTICLE  V. 

PROGNOSIS. 

The  prognosis  of  abortion  is  necessarily  variable,  according  to  the  time 
of  its  occurrence  and  the  cause  which  has  produced  it.  As  regards  the 
foetus,  it  is  always  mortal,  since  the  expulsion  takes  place  before  the  pro- 
duct of  conception  is  fitted  for  an  extra-uterine  life,  though  I  am  well  aware 
that  cases  are  reported  of  children,  born  prior  to  the  period  of  viability 
fixed  by  law,  which  have  lived  ;  but  these  examples,  even  were  they  authen- 
tic, are  too  rare  to  invalidate  the  general  proposition  just  laid  down. 

As  regards  the  mother,  the  prognosis  is  said  to  be  more  grave  than  thai 
of  labor  at  term;  but  this  proposition,  which  has  been  advocated  since  the 
days  of  Hippocrates,  requires  explanation,  and  should  not  be  received  with- 
out some  restriction ;  for  the  prognosis,  considered  in  relation  to  immediate 
consequences,  is  certainly  less  serious  in  a  case  of  abortion  than  in  a  natural 
labor  ;  but  the  remote  effects  are  undoubtedly  more  disastrous  in  the  former 
case.     Thus,  the  acute  diseases  which  attack  lying-in  women  are  more  ire- 


OF   ABORTION.  5  i  !  > 

quent  after  labor,  whilst  the  chronic  disorders  of  the  genital  organs  which 
appear  in  advanced  age  are  more  common  with  females  who  have  often 
aborted  than  with  those  who  have  always  been  delivered  at  term.1  Again, 
it  is  highly  important  to  notice  the  unfavorable  influence  that  one  abortion 
seems  to  have  over  subsequent  pregnancies ;  for  whenever  a  woman  has  had 
a  miscarriage,  she  is  more  predisposed  than  others  to  a  similar  accident,  and 
hence  great  precautions  should  always  be  taken  to  prevent  it. 

The  period  at  which  an  abortion  occurs  also  influences  the  prognosis, 
although  we  cannot  exactly  say,  with  Desormeaux,  that  it  is  more  serious 
for  the  patient  in  the  advanced  stages  of  gestation.  Doubtless,  as  before 
stated,  it  scarcely  constitutes  an  indisposition  in  the  first  or  even  the 
second  month ;  but  in  the  third  or  fourth,  the  expulsion  of  the  foetus  de- 
mands a  certain  dilatation  of  the  os  uteri,  and  tolerably  energetic  contrac- 
tions ;  for  the  neck  and  body  of  the  uterus  have  not  as  yet  undergone  the 
modifications  necessary  to  such  an  effort,  and  the  delivery  of  the  after-birth 
often  presents  difficulties  less  frequently  met  with  at  a  more  advanced  stage 
of  gestation  ;  whence  I  conclude,  that  an  abortion  is  then  more  grave  and 
painful  to  the  patient,  as  also  more  dangerous,  than  in  the  fifth  or  the  sixth 
month. 

Lastly,  the  prognosis  varies  with  the  cause  of  the  accident.  Thus,  the 
most  serious  of  all  is  an  abortion  brought  on  either  by  medicines  adminis- 
tered internally  or  by  manipulations ;  while  a  miscarriage  determined  by 
slow  and  gradual  influences  is  usually  attended  with  less  danger  than  one 
caused  by  external  violence  or  some  powerful  moral  commotion.  In  this 
latter  case,  the  hemorrhage  which  precedes,  accompanies,  or  follows  the 
abortion,  is  nearly  always  much  more  serious.  Lastly,  when  it  occurs  in 
the  course  of  an  acute  inflammation  of  an  important  organ,  or  during  the 
existence  of  an  acute  disease  of  the  skin,  it  is  exceedingly  dangerous. 

AKTICLE   VI. 

TREATMENT   OF   ABORTION. 

The  treatment  of  abortion  consists  in  preventing  it,  in  favoring  the  expul- 
sion of  the  ovum  when  this  is  inevitable,  and  in  remedying  the  various  acci- 
dents that  may  complicate  it. 

1.  Preventive  Measures. —  When  the  miscarriage  is  dependent  on  the 
woman's  bad  constitution,  or  on  a  lesion  of  the  genital  organs,  we  must  en- 
deavor to  combat  and  destroy  this  pernicious  predisposition,  more  especially 
in  the  intervals  between  the  gestations.  I  shall  say  nothing  at  this  time  of 
the  means  of  modifying  the  general  vices  of  the  constitution,  since  they 
necessarily  vary  with  the  nature  of  the  affection.  It  is  particularly  impor- 
tant, however,  to  bear  in  mind  the  disastrous  influence  of  syphilis,  whether 
the  father  or  the  mother  be  infected  with  it,  over  the  life  of  the  foetus ;  and 
we  should  persuade  them  to  submit  to  a  mercurial  course. 

1  Would  it  be  unreasonable  to  suppose  that,  inasmuch  as  women  who  have  had  fre- 
quent miscarriages  are  particularly  liable  to  chronic  diseases,  the  tendency  may  be 
due  to  the  fact  that  they  have  long  borne  the  germ  which  occasioned  their  previous 
•abortions  1     Which  was  the  caun  and  which  the  etfect?     (Blot.) 


580  PATHOLOGY    OF    PREGNANCY. 

When  it  happens  that  several  abortions  have  resulted  in  consequence  of 
some  displacement  of  the  uterus,  the  latter  should  be  remedied  by  the 
appropriate  measures :  for  instance,  in  the  commencement  of  pregnancy,  the 
woman  should  avoid  all  fatigue  and  every  violent  effort;  and  it  is  even 
advisable  for  her  to  remain  in  the  recumbent  position  until  the  uterus  rises 
above  the  superior  strait. 

We  award  the  proper  value  to  the  influence  attributed  by  Desormeaux 
to  the  supposed  rigidity  and  excess  of  sensibility  or  contractility  in  the 
uterine  fibre,  as  well  as  to  the  excessive  weakness  or  relaxation  in  the  fibres 
of  the  neck.  But,  whilst  interpreting  the  action  of  those  causes  in  a  differ- 
ent manner,  we  believe,  with  him,  that  bathing,  general  bleeding,  opiate 
injections,  and  a  regulated  course  of  living,  are  the  means  best  suited  to 
moderate  this  great  irritability  of  the  organ  ;  and  that  a  tonic  and  strength- 
ening regimen,  aided  by  the  ferruginous  preparations,  cold  baths,  and  the 
chalybeate  mineral  waters,  will  be  the  most  usefully  employed  in  those 
cases  wThere  the  general  debility  of  the  patient  may  have  seemed  to  exercise 
some  influence  over  her  former  abortions. 

Plethoric  women,  who  usually  have  profuse  menstrual  discharges,  and 
who  may  have  previously  suffered  from  abortion  at  the  periods  of  menstrua- 
tion, all  of  which  had  been  preceded  by  the  symptoms  of  general  or  local 
plethora,  and  all  followed  by  more  or  less  copious  discharges,  should  be 
subjected  before  fecundation  to  a  restricted  regimen  ;  and  during  gestation, 
they  should  avoid  all  moral  and  physical  excitements,  and  should  remain 
in  bed  eight,  ten,  or  even  twelve  days  at  every  monthly  term  ;  besides,  they 
ought  to  be  bled  several  times  during  the  earlier  periods  of  pregnancy,  more 
especially  just  before  the  time  for  the  menses  to  appear.1 

These,  more  than  other  pregnant  women,  should  renounce  the  use  of  cor- 
sets, which,  independently  of  the  restraint  they  make  on  the  development 
of  the  breasts,  oppose  the  free  return  of  blood,  by  interfering  more  or  less 
with  the  abdominal  and  thoracic  circulation,  and  thereby  favor  congestion 
of  the  inferior  organs. 

Feeble,  cachectic  females,  who  are  impaired  by  former  diseases,  and  those 
whose  tissues  are  soft,  and  their  circulation  languid,  or  who,  from  being 
habitually  irregular,  are  affected  with  chronic  leucorrhcea,  are  often  attacked 
by  hemorrhages  during  pregnancy  which  ultimately  lead  to  an  abortion. 

In  such  patients  the  face  is  pale,  the  pulse  soft,  small,  and  irritable,  the 
tongue  white,  digestion  painful,  the  intestines  torpid,  and  the  extremities  cold. 
The  least  exercise  fatigues  them,  sometimes  even  exhausts  their  strength. 
The  fatigue  is  often  accompanied  by  a  sensation  of  weight,  of  painful  drag- 
gings  in  the  groins  and  lumbar  regions,  and,  should  they  remain  standing 
for  any  length  of  time,  the  uterus  seems  to  require  some  support,  as  it  ap 
pears  just  on  the  point  of  escaping  by  the  vagina  or  rectum.     Even  in  the 

1  The  physician  often  meets  with  much  opposition  from  persons  out  of  the  profession 
when  In-  j.rojMis.-s  .-i  [ireventive  bleeding  in  the  early  stages  of  gestatioD.  Particularly, 
should  any  accident  happen  shortly  afterwards,  they  would  not.  fail  to  reproach  him 
with  it.  This,  however,  is  no  just  reason  for  not  acting  according  to  his  convictions, 
or  for  yielding  in  cases  where  he  believes  it  really  useful.  Now,  experience  has  fully 
proved  that,  in  such  instances  as  those  we  have  described,  it  is  one  of  the  best  pre- 
ventive measures. 


OF    ABORTION.  581 

earliest  stages,  they  feel  something  like  a  weight  in  the  lesser  pelvis,  always 
pressing  on  the  most  dependent  part. 

Now,  the  best  mode  of  preventing  such  a  condition,  is  to  prescribe  a  tonic 
regimen,  together  with  the  ferruginous  and  bitter  preparations.  Canella,  in 
powder,  has  been  recommended ;  and  Sauter  highly  extols  the  use  of  pow- 
dered savine ;  he  asserts,  that  he  has  succeeded  in  correcting  this  pernicious 
predisposition  in  pregnant  women,  who  had  previously  had  several  mis- 
carriages, by  administering  fifteen  grains  of  the  powder  three  times  a  day, 
continuing  it  for  three  or  four  months  ;  by  this  remedy  he  has  arrested  flood- 
ing and  prevented  abortion,  and  many  patients  can  attribute  the  fact  of 
having  children  born  at  full  term  to  the  employment  of  this  precious  drug. 

White,  of  Manchester,  has  particularly  recommended  cold  bathing,  espe- 
cially sea-bathing,  to  be  often  repeated,  both  before  and  during  pregnancy. 

The  accoucheur  must  therefore  search  in  the  history  of  former  miscarriages 
for  the  indications  to  guide  him  in  the  use  of  preventive  measures ;  and  it 
is  likewise  very  important  that  he  should  make  himself  acquainted  with  all 
the  accompanying  circumstances. 

Pregnant  women  are  very  often  constipated,  and  this  constipation  fre- 
quently becomes  the  cause  of  periodic  abortions,  by  the  irritation  it  pro- 
duces ;  hence,  it  should  be  prevented  by  the  use  of  some  simple  injections, 
with  the  addition  of  one  or  two  tablespoonfuls  of  linseed-oil,  regularly,  every 
other  day,  for  two  weeks  before  the  period  when  the  abortion  occurred  last 
time,  and  they  ought  to  be  continued  for  two  weeks  after  it. 

But  whatever  may  have  been  the  predisposing  cause  whose  influence  was 
exerted  in  the  previous  pregnancies,  there  is  one  very  important  precaution, 
the  neglect  of  which  might  render  all  others  useless.  In  all  cases  where 
abortion  has  occurred  several  times,  it  is  indispensable  that  the  organ  should 
remain  undisturbed,  and  the  husband  be  recommended  to  allow  from  six  to 
eight  months,  or  even  a  year  to  elapse,  without  the  wife  being  exposed  to 
become  pregnant. 

When  this  accident  has  already  occurred  a  number  of  times  in  former 
pregnancies,  it  is  always  indispensable  for  the  woman  to  abstain  altogether 
from  intercourse  with  her  husband,  for  all  sources  of  irritation  must  evi- 
dently be  withdrawn  from  the  womb.  Again,  if  the  foetus  was  expelled 
dead  in  the  preceding  gestations,  and  this  death  had  been  caused  by  some 
lesion  of  the  ovum,  it  is  almost  impossible  to  recognize,  and  consequently  to 
prevent,  a  similar  alteration. 

The  case  is  rather  different  when  the  previous  abortions  have  been  attri- 
buted to  utero-placental  or  intra-placental  effusions,  for  these  are  almost 
always  the  result  of  a  congestion  of  the  uterus,  of  sufficient  intensity  to  j:>ro- 
duce  a  rupture  of  vessels.  In  another  pregnancy,  it  might  be  possible  to 
avoid  such  accidents.  We  would,  however,  call  attention  to  the  fact,  that 
these  local  congestions  may  occur  in  chlorotic  as  well  as  in  plethoric 
women,  and  consequently,  that,  although  revulsives  applied  to  the  upper  part 
of  the  body,  or  to  the  superior  extremities,  are  useful  in  all,  bleedings  from 
the  arm  at  the  menstrual  periods  are  very  advantageous  with  the  latter 
whilst  the  foimer  are  benefited  by  the  preventive  use  of  ferruginous  pre- 
parations, administered  from  the  commencement  of  gestation. 


582  PATHOLOGY  OF  PREGNANCY. 

Under  some  unfortunate  circumstances,  nature  seems  to  deride  all  ihe 
attempts  of  art,  and  abortion  reoccurs.  Still,  we  must  not  despair  when 
the  woman  becomes  again  pregnant,  for  experience  fully  proves  that,  not- 
withstanding numerous  former  abortions,  a  fresh  pregnancy  has  sometimes 
succeeded  in  reaching  full  term.  Dr.  Young  (Eigby,  91)  relates,  in  his 
lectures,  the  history  of  an  unfortunate  lady,  who,  after  having  had  thirteen 
successive  abortions,  became  pregnant  for  the  fourteenth  time,  and  was  hap- 
pily delivered  of  a  living  infant  at  term. 

But,  notwithstanding  all  these  precautions,  it  sometimes  happens  that  an 
abortion  is  threatened.  The  patients  are  affected  with  shiverings  from  the 
most  trifling  causes,  pains  in  the  hypogastrium,  loins,  &c. ;  uterine  con- 
tractions appear,  the  sexual  parts  become  moist,  and  occasionally  even  the 
os  uteri  dilates;  but  even  here  we  must  not  lose  all  hopes  of  arresting  the 
accident,  notwithstanding  those  symptoms. 

If  the  patient  is  robust,  the  pulse  full  and  frequent,  more  especially  if 
the  development  of  the  symptoms  had  been  preceded  by  indications  of 
plethora,  bleeding  in  the  arm  should  be  at  once  resorted  to,  the  woman  be 
laid  as  horizontally  as  possible,  and  opiates  immediately  administered.  The 
laudanum  of  Sydenham  may  be  given  in  the  dose  of  twenty,  forty,  or  even 
sixty  drops,  diffused  in  a  small  quantity  of  some  mucilaginous  liquid  as  an 
injection,  and  repeated  at  intervals  of  an  hour,  until  the  contractions  dis- 
appear. This  remedy,  of  which  we  have  before  spoken,  is  one  of  the  most 
efficacious  in  cases  of  this  kind,  and  sometimes  it  alone  has  enabled  us  to 
arrest  a  labor  whose  termination  seemed  to  be  inevitable,  and  thus  has  per- 
mitted the  gestation  to  pursue  its  regular  course. 

I  cannot  refrain  from  citing  the  following  instance  in  illustration.  A 
woman,  advanced  to  three  months  and  a  half,  was  taken  with  pains  in  the 
abdomen  and  loins,  after  a  violent  altercation  with  her  husband ;  on  the 
following  day  the  pains  augmented,  and  a  little  bloody  fluid  escaped  from 
the  genital  organs ;  the  pains  still  continuing,  and  the  discharge  having 
somewhat  increased,  on  the  third  day  the  patient  came  on  foot  to  the 
Clinique.  I  found  on  her  arrival  that  the  uterine  contraction  was  very  dis- 
tinct, the  pains  sharp,  and  renewed  every  eight  or  ten  minutes ;  pure  blood 
was  discharging  from  the  vulva,  and  the  orifice  was  sufficiently  dilated  to 
permit  the  finger  to  pass  readily  as  far  tip  as  the  naked  membranes.  I  ad- 
ministered sixty  drops  of  laudanum,  divided  into  three  doses,  which  were 
given  at  intervals  of  three  quarters  of  an  hour,  and  by  the  end  of  this  time 
the  pains  disappeared,  everything  resumed  its  natural  order,  and  the  gesta- 
tion went  on  till  full  term. 

I  might  multiply  such  citations  almost  ad  infinitum,  but  the  above  is  suf- 
ficient to  show  that,  however  inevitable  the  abortion  may  at  first  appear,  we 
should  never  abandon  all  hopes  of  preventing  it.  I  may  add,  that  the 
administration  of  opium  in  the  doses  just  indicated,  or  even  carried  to  a 
hundred  drops  in  the  twenty-four  hours,  has  never  been  followed  by  serious 
consequences.  Sometimes,  perhaps,  a  little  somnolency  or  heaviness  about 
the  head,  or  a  general  torpor  may  result,  but  which  a  few  glasses  of  lemonade 
will  soon  dissipate.  For,  after  all,  when  even  death  of  the  foetus  must  have 
been  either  the  cause  or  the  effect  of*  the  primary  symptoms,  what  do  we 


OF    ABORTION".  583 

risk  in  calming  or  arresting  the  uterine  contractions  ?  because,  as  we  have 
already  seen,  the  dead  child  may  remain  long  within  the  intact  membranes 
without  any  unfavorable  consequences  resulting  to  the  mother.  And 
besides,  as  it  is  almost  impossible  to  ascertain  its  death  with  any  degree  of 
certainty  prior  to  the  fifth  month  of  gestation,  we  must  act  in  such  doubtful 
cases  just  as  if  it  were  living ;  although  there  can  be  no  question  that,  if  the 
foetus  were  really  dead,  it  would  be  better  to  permit  the  contractions  to  go 
on,  and  its  expulsion  to  be  effected.  But,  even  supposing  these  are  wholly 
suspended,  the  expulsion  is  somewhat  retarded,  and  that  is  all ;  for  after  the 
lapse  of  a  certain  time  the  foetus,  acting  like  a  foreign  body  in  the  uterine 
cavity,  will  irritate  its  walls,  and  a  new  labor  sooner  or  later  take  place  in 
consequence. 

To  these  remedies  (the  venesection  and  opiate  treatment)  we  must  add 
strict  confinement  to  bed,  absolute  rest  of  mind  and  body,  the  use  of  demul- 
cent beverages,  cold  lemonade,  veal-broth,  chicken-water,  and  the  applica- 
tion of  cold  compresses,  frequently  renewed,  over  the  abdomen ;  which  com- 
presses are  to  be  saturated  with  some  fluid  whose  temperature  is  progressively 
lowered.  "  Local  bleedings,"  says  M.  Gendrin,  "  are  too  much  neglected, 
especially  in  the  treatment  of  the  utero-placental  hemorrhages ;  indeed,  we 
have  so  often  had  occasion  to  congratulate  ourselves  for  having  advised 
them  in  those  cases,  that  we  now  prescribe  them  with  great  confidence  when- 
ever the  general  condition  does  not  directly  indicate  a  depletory  venesection. 
We  direct  them  :  1.  When  there  are  any  sharp  pains  in  the  neighborhood 
of  the  uterus  or  groins,  and  we  apply  them  to  the  latter,  the  anus,  or  even 
the  vulva ;  2.  In  cases  of  a  considerable  turgescence  of  the  hemorrhoidal 
tumors  (if  any  such  exist) ;  and  3.  In  the  phlegmasia  of  the  adjacent 
organs,  such  as  the  large  intestine,  &c." 

In  these  two  latter  cases  we  fully  coincide  in  the  opinion  of  M.  Gendrin ; 
but,  in  the  first,  we  should  much  prefer  having  recourse  to  a  general  bleeding 
in  the  arm,  or,  as  he  himself  advises,  further  on,  to  the  application  of 
leeches  at  a  distance  from  the  uterus  :  for  instance,  near  the  breasts,  armpits, 
&c,  &c.  Finally,  to  the  means  already  enumerated,  we  must  further  add 
the  use  of  irritant  revulsives,  placed  upon  the  upper  part  of  the  trunk  and 
the  thoracic  extremities,  and  must  also  recommend  in  a  more  special 
manner  the  application  of  dry  cups,  the  decidedly  beneficial  effects  of  which 
we  have  often  witnessed  in  cases  where  uterine  plethora  seemed  to  be  the 
cause  of  the  symptoms,  but  where  the  general  condition  required  some  pre- 
caution in  the  use  of  blood-letting. 

2.  It  has  been  already  stated  that  a  copious  hemorrhage,  intensity  of 
the  pain  and  of  all  the  other  phenomena,  and  more  particularly  a  rupture 
of  the  membranes,  render  abortion  thenceforth  inevitable ;  and  hence,  the 
only  course  in  such  cases  is  to  facilitate  the  expulsion  of  the  product  of 
conception.  But  still,  if  the  hemorrhage  is  not  of  such  a  character  during 
the  first  three  months  of  gestation  as  to  compromise  the  woman's  life,  the 
physician  should  remain  a  simple  spectator  of  the  efforts  of  nature,  and 
confine  himself  to  superintending  the  progress ;  for  the  expulsion  of  the 
ovum  ought  to  be  left  entirely  to  the  uterine  forces.  Sometimes  it  comes 
away  whole,  which  is  a  very  favorable  circumstance.     Moreover,  according 


584  PATHOLOGY    OF    PREGNANCY. 

to  the  recommendation  of  Baudelocque,  he  should  be  very  careful  not  tc 
rupture  the  membranes,  for  that  would  only  retard  the  delivery  of  the 
placenta,  and  render  it  still  more  dangerous.  In  fact,  when  the  foetus* 
escapes  alone,  this  latter  might  be  attended  with  the  difficulties  pointed  out 
in  one  of  the  preceding  articles. 

We  should  here  remember  how  slowly  the  expulsion  of  the  ovum  is 
effected  in  certain  cases,  even  when  the  orifice  is  sufficiently  dilated  to 
oppose  no  obstruction  to  its  exit.  This  great  slowness  is  sufficiently  ex- 
plained by  the  slight  contractile  power  of  the  uterus.  When  no  accident 
complicates  the  abortion,  the  physician  has  nothing  to  do  but  watch  the 
progress  of  the  labor,  and  expect  the  complete  delivery  to  be  effected  by 
the  uterine  efforts.  At  a  more  advanced  period,  that  is,  towards  the  fifth 
or  the  sixth  month,  the  course  of  the  physician  is  very  nearly  the  same  as 
it  would  be  at  term.  The  size  of  the  foetus,  which  has  now  become  quite 
large,  requires  a  greater  dilatation  of  the  os  uteri ;  and  this,  in  consequence  of 
the  greater  softening  of  the  cervix,  is  accomplished  with  somewhat  greater 
rapidity.  Generally,  it  is  necessary  that  the  child  should  present  one  or 
the  other  extremity  of  its  long  diameter  to  the  os  uteri ;  however,  it  some- 
times happens  that  some  portion  of  its  trunk  presents  there,  and  its  delivery 
is  neither  much  more  difficult  nor  much  slower  than  usual.  It  is  in  such 
cases  especially  that  the  mechanism  of  spontaneous  evolution  may  be  fre- 
quently observed.  The  delivery  of  the  after-birth  does  not,  as  a  general 
rule,  exhibit  those  difficulties  which  it  presented  in  the  earlier  months ;  in 
truth,  it  closely  resembles  the  same  process  in  the  labor  at  term. 

3.  Hemorrhage  is  not  only  one  of  the  most  common  symptoms,  but  it  may  fol- 
low the  expulsion  of  the  foetus,  and  become  the  most  serious  feature  of  the  case. 

Whenever,  notwithstanding  the  use  of  general  measures,  such  as  the 
horizontal  position,  cold  drinks,  the  application  of  refrigerants  to  the  hypo- 
gastrium  or  thighs,  and  the  administration  of  opiates,  the  discharge  of 
blood  continues  so  great  as  to  endanger  the  mother's  life,  an  abortion  thence- 
forth becomes  inevitable,  and  the  primary  object  of  the  accoucheur  should 
be  to  bring  on  the  contractions  and  the  evacuation  of  the  organ. 

He  should  also  administer  general  stimulants  to  sustain  the  woman's 
Btrength,  and,  at  the  same  time,  those  medicines  having  an  immediate  action 
on  the  womb  itself,  such  as  the  tincture  of  canella,  &c,  but  above  all  the 
ergot.  However,  when  the  miscarriage  comes  on  at  an  early  stage  of  the 
gestation,  these  measures  are  often  ineffectual,  for  it  is  then  exceedingly  diffi- 
cult to  excite  the  contractions  of  a  viscus  whose  muscular  organization  is 
etill  so  imperfect ;  or  at  least,  if  they  are  aroused,  they  are  frequently 
inadequate  to  dilate  the  neck  sufficiently.  The  tampon  is  then  the  only 
resource ;  this,  when  well  applied,  acts  in  two  ways :  1st,  by  opposing  the 
escape  of  the  blood  externally,  thus  forcing  it  to  coagulate,  and  conse- 
quently to  obliterate  the  bleeding  vessels ;  2d,  by  irritating  the  womb  by 
mere  contact,  thereby  determining  its  retraction,  and  the  expulsion  of  the 
product  of  conception.  This  circumstance,  indeed,  is  one  of  the  best- 
founded  objections  to  the  use  of  the  tampon  in  the  early  months  of  gesta- 
tion. But,  in  truth,  is  it  not  rather  an  advantage  than  otherwise?  because 
the   cessation  of  the    Hooding  is  always  a  necessary  consequence  of  the 


OF   EXTRA-UTERINE    PREGNANCY.  585 

uterine  contractions;  and  is  the  mother's  life  bought  too  dear,  when  ii  i.< 
saved  by  the  expulsion  of  a  foetus  which,  in  most  cases,  is  dead  even  before 
the  application  of  the  tampon  ?  Besides,  this  measure  is  not  always 
necessarily  followed  by  abortion.  Again,  i aere  is  no  reason  to  fear  the 
conversion  of  an  open  into  a  concealed  hemorrhage  by  the  employment  of 
the  tampon,  before  the  sixth  month ;  for,  notwithstanding  the  observation 
of  Chevallier,  the  accumulation  of  a  large  quantity  of  blood  in  the  womb 
would  seem  to  be  impossible  at  this  early  period,  without  supposing  an  ab- 
normal relaxation  of  its  walls.  Where,  however,  the  pregnancy  is  advanced 
to  the  fifth  month,  the  accoucheur  should  carefully  watch  the  body  of  the 
uterus  after  the  tampon  is  applied,  and  assure  himself,  every  moment,  that 
its  volume  is  not  increasing. 

We  shall  describe  hereafter  (see  Operations)  the  mode  of  applying  the 
tampon,  but  it  should  be  remembered  that  its  use  is  almost  always  followed 
by  abortion,  and  that  it  should  be  had  recourse  to  only  when  the  latter 
seems  to  be  inevitable. 

When  the  ovum  remains  intact,  and  the  labor  lasts  too  long,  the  contin- 
uation of  the  hemorrhage  being  at  the  same  time  such  as  to  cause  serious 
anxiety,  some  practitioners  prefer  rupturing  the  membranes  to  applying  the 
tampon.  This  measure,  to  which  I  shall  again  allude  in  speaking  of  hem- 
orrhage during  the  last  three  months,  does  not  seem  to  me  applicable  before 
the  sixth  month,  except  in  a  few  occasional  instances,  and  I  should,  in 
general,  decidedly  prefer  the  tampon  to  it. 

In  fact,  a  rupture  of  the  membranes  is  necessarily  followed  by  miscar- 
riage ;  but  the  tampon,  when  early  applied,  leaves  some  hope  that  the  ges- 
tation may  continue  till  term ;  again,  the  tampon  always  arrests  the  bleed- 
ing, whereas,  after  rupturing  the  membranes,  it  may  happen  that  the  uterus, 
whose  muscular  fibres  have  not  acquired  the  contractile  power  which  they 
would  have  at  a  later  period,  might  not  retract,  nor  the  hemorrhage  cease, 
so  that  it  might  still  be  necessary  to  have  recourse  to  the  tampon. 

Finally,  let  us  add  that,  in  the  first  three  months,  the  rupture  is  followed 
almost  immediately  by  a  discharge  of  the  waters  and  the  escape  of  the 
fcetus ;  but  the  expulsion  of  the  placenta  and  membranes  is  thereby  rendered 
much  more  difficult. 

After  the  complete  expulsion  of  the  ovum,  the  patient  must  observe  the 
same  precautions  as  are  required  after  ordinary  labor. 


CHAPTER   VI. 

OF   EXTRA-UTERINE   PREGNANCY.' 

The  fecundation,  as  elsewhere  stated,  most  frequently  takes  place  in  thi 
ovary,  and  the  impregnated  ovule  is  then  received  by  the  fimbriated  extrem- 
ity of  the  tube,  which  applies  itself  on  this  organ,  doubtless  by  a  kind  of 
spasmodic  contraction.  Having  beei  once  deposited  in  the  tubal  canal,  the 
ovule  traverses  its  whole  length,  and  falls  into  the  uterine  cavity,  where  it« 

1  See  page  1165. 


586  PATHOLOGY  OF  PREGNANCY. 

development  continues  until  term.  Such  is  the  course  observed  in  normal 
or  uterine  pregnancy ;  but  it  may  happen  that  the  ovule  is  arrested,  or 
diverted,  in  the  route  it  thus  travels,  and  ingrafting  itself,  so  to  speak,  upon 
the  point  of  stoppage,  is  there  developed ;  in  the  latter  case,  the  pregnancy 
is  called  an  abnormal,  or  an  extra-uterine  one. 

This  species  of  gestation  has  been  subdivided  into  several  varieties,  which 
have  received  different  names,  according  to  the  part  of  the  passage  where 
the  ovule  becomes  fixed.  Dezeimeris  admitted  the  following  divisions, 
namely : 

1.  Ovarian  pregnancy. 

2.  Sub-peritoneo-pelvic  pregnancy. 

3.  Tubo-ovarian  pregnancy. 

4.  Tubo-abdominal  pregnancy. 

5.  Tubal  pregnancy. 

6.  Tubo-uterine  interstitial  pregnancy. 

7.  Utero-interstitial  pregnancy. 

8.  Utero-tubal  pregnancy. 

9.  Utero-tubo-abdominal  pregnancy. 
10.  Abdominal  pregnancy. 

Such  was  the  classification  which,  in  an  anatomo-pathological  view,  was 
adopted  in  the  six  first  editions  of  this  work.  We  now  think  it  would  be 
better  to  make  a  more  simple  arrangement,  and  shall,  accordingly,  describe 
but  five  varieties  of  extra-uterine  pregnancy : 

1.  Abdominal  pregnancy. 

2.  Tubo-abdominal  pregnancy. 

3.  Tubal  pregnancy. 

4.  Interstitial  tubo-uterine  pregnancy. 

5.  Utero-tubal  pregnancy. 

1.  Abdominal  Pregnancy.  — To  render  fecundation  possible,  it  is  necessary 
i  hat  there  should  be  direct  contact  between  the  sperm  and  the  ovule,  and, 
consequently,  that  the  Graafian  vesicle  should  burst  into  the  abdominal 
cavity  of  which  it,  for  the  moment,  forms  a  portion.  But,  should  the  fecun- 
dated ovule,  instead  of  engaging  in  the  tube,  remain  in  the  just  ruptured 
ovisac  and  be  retained  at  the  surface  of  the  ovary,  or  fall  into  the  peritoneal 
cavity,  its  development  gives  rise  to  an  extra-uterine  pregnancy  which  we 
shall  designate  under  the  general  name  of  abdominal  pregnancy.  Three 
varieties  of  this  class  will  be  recognized :  in  the  first,  the  fecundated  ovule 
is  still  contained  in  the  just  ruptured  ovisac,  and  is  developed  upon  the 
spot :  the  pregnancy  is  then  styled  internal  ovarian.  In  the  second  variety, 
the  fecundated  ovule,  having  escaped  from  the  Graafian  vesicle,  adheres  to 
the  surface  of  the  ovary,  where  it  undergoes  development :  this  is  called 
external  ovarian  pregnancy.  Finally,  should  the  ovule,  after  leaving  the 
ovary,  attach  itself  to  some  part  of  the  peritoneum,  it  receives  the  name  of 
peritoneal  pregnancy. 

In  internal  ovarian  pregnancy,  the  ovum  is  developed  within  the  ovary 
itself.  This  variety  has  given  rise  to  numerous  scientific  discussions,  inas- 
much as  it  was  for  a  long  time  admitted  that  the  ovule  could  be  fecundated 


OF    EXTRA-UTERINE    PREGNANCY.  58  i 

without  previous  rupture  of  the  Graafian  vesicle.  Amongst  the  observa- 
tions pleaded  in  favor  of  this  hypothesis,  one  related  by  Bcehmer  ought  to 
be  mentioned.  He  describes  with  much  care  both  the  membrane  proper 
of  the  ovary  itself  and  its  peritoneal  envelope.  M.  Velpeau,  however,  very 
justly  observes  that  it  is. often  extremely  difficult  to  determine  precisely  the 
point  of  departure  of  the  tumor ;  therefore  we  admit  with  him  that,  in  this 
species  of  pregnancy,  the  ovisac  is  always  ruptured.  If  the  minute  wound 
resulting  from  it  be  not  evident  when  the  dissection  is  made,  it  is  because  it 
has  been  obliterated  by  the  process  of  cicatrization  and  the  production  of  a 
newly-formed  membrane. 

External  ovarian  pregnancy  cannot  be  doubted.  It  is,  relatively  speak- 
ing, quite  common,  and  the  fecundated  ovule  retains  its  intimate  connections 
with  the  ovary  upon  which  it  is  applied  whilst  undergoing  development  in 
the  abdominal  cavity. 

Peritoneal  pregnancy  was  for  a  long  time  contested,  but  is  now  supported 
by  so  great  an  array  of  facts,  observed  both  in  women  and  animals,  that  it 
is  impossible  to  deny  its  occurrence.  It  has,  doubtless,  often  been  con- 
founded with  the  ovarian  and  other  forms,  but  in  several  published  cases 
there  can  be  no  question  that  the  ovum  had  no  connection  with  the  internal 
generative  organs.  M.  Dezeimeris  makes  two  varieties  of  this  form  of 
pregnancy,  viz. :  primitive  and  secondary.  In  the  former,  the  product  of 
conception  has  never  been  located  elsewhere  than  in  the  peritoneal  cavity, 
into  which  it  fell  on  quitting  the  ovarian  vesicle ;  in  the  latter,  on  the  con- 
trary, the  first  development  of  the  ovule  took  place  in  the  ovary,  the 
tube,  or  the  walls  of  the  uterus,  but  at  a  later  period  extreme  distention  or 
pathological  alteration  of  the  walls  of  the  tumor  caused  their  rupture,  and 
the  ovum  being  partly  or  wholly  expelled  from  the  containing  cyst,  became 
lodged  in  the  cavity  of  the  abdomen,  where  it  was  at  last  found.  The  sec- 
ondary abdominal  pregnancy  of  M.  Dezeimeris  is,  therefore,  merely  a  tubal 
or  interstitial  pregnancy,  ending  in  rupture  of  the  primitive  cyst.  Whether, 
therefore,  this  rupture  occurs  at  a  very  early  period  or  at  the  regular  term 
of  gestation,  it  deserves  to  be  regarded  merely  as  an  epiphenomenon,  and 
can,  in  no  case,  constitute  a  distinct  variety.  We  apply,  therefore,  the 
name  peritoneal  pregnancy  to  that  form  in  which,  from  the  very  outset,  the 
ovule  has  become  adherent  to  some  part  entirely  distinct  from  the  internal 
generative  organs.  The  points  at  which  it  may  thus  attach  itself  are  ex- 
tremely numerous,  so  that  the  placenta  has  sometimes  been  found  inserted 
upon  the  peritoneum,  covering  the  right  or  left  iliac  fossa,  sometimes  to  the 
mesentery,  or  to  a  part  of  the  small  and  large  intestine,  and  sometimes, 
finally,  to  the  anterior  wall  of  the  abdomen. 

Most  of  the  cases  described  by  Dezeimeris  as  snb-peritoneo-pelvic  preg- 
nancies belong,  we  think,  to  the  peritoneal  variety.  The  author  applies  the 
former  name  to  cases  in  which  the  ovule  was  unable,  after  leaving  the  ovary, 
to  engage  in  the  external  opening  of  the  tube,  but  slipped  between  the  two 
layers  of  the  broad  ligaments  and  was  developed  there.  According  to  his 
view,  the  ovum  here  is  outside  of  the  peritoneum,  and  remains  principally 
in  the  pelvic  cavity.  Cases  of  the  kind,  he  thinks,  are  not  rare,  and,  on 
account  of  the  situation  of  the  ovum,  are  to  be  reckoned  amongst  the  least 


588  PATHOLOGY  OF  PREGNANCY. 

dangsrous.  The  position  is,  indf.ed,  remarkably  favorable  to  the  sponta- 
neous expulsion  of  the  debris  of  the  foetus,  or  makes  them  easily  accessible 
in  case  it  should  be  thought  necessary  to  abstract  them.  Whilst  accepting 
this  prognosis,  we  think  that  Dezeimeris  is  in  error  as  regards  the  slipping 
of  the  ovule  between  the  two  layers  of  the  broad  ligament ;  it  seems  to  me 
impossible  that  it  should  follow  this  route.  The  observers  were,  in  these 
cases,  deceived  by  the  fact  that  upon  opening  the  abdomen  the  peritoneum 
of  the  lesser  pelvis  seemed  to  be  raised  by  a  subjacent  tumor.  The  appear- 
ance, however,  misled  them,  for  the  tumor  is  not,  really,  covered  by  the 
peritoneum,  but  by  a  newly-formed  false  membrane,  which  soon  acquires 
the  shining  and  polished  appearance  of  a  serous  membrane,  and  which 
blends,  without  a  well-marked  line  of  demarcation,  with  the  surrounding 
peritoneum.  If  this  pseudo-membrane  be  incised,  a  careful  dissection  will 
reveal  the  true  peritoneum  below  the  foetal  cyst.  The  tumor,  therefore,  is 
not  extra-peritoneal,  but  intra-peritoneal.  In  short,  the  same  phenomenon 
occurs  here  which  for  a  long  time  sustained  the  idea  that  retro-uterine 
hematocele  was  seated  outside  of  the  peritoneum. 

2.  Tubo-abdominal  Pregnancy. — It  is  evident  that,  if  the  tube  be  obliter- 
ated near  the  enlarged  extremity,  the  ovule  which  has  scarcely  entered  its 
canal  will  be  arrested  ;  and  if  the  development  occurs  at  this  point,  the  tubal 
walls  will  necessarily  be  dilated,  and  one  portion  of  the  surface  of  the  ovum 
be  free  in  the  abdominal  cavity;  to  this  variety  the  name  of  tubo-abdomiixil 
is  applied.  The  placenta  is  attached  in  the  interior  of  the  tube,  and  the 
fcetus  developed  in  the  abdominal  cavity,  and  both  are  surrounded  by  a  cyst, 
the  walls  of  which  are  partly  made  up  by  the  parietes  of  the  tube. 

We  include  in  the  tubo-abdominal  pregnancies  those  cases  which  have 
been  described  under  the  name  of  tubo-ovarian.  In  this  the  cyst,  which 
surrounds  the  fcetus,  is  formed  partly  by  the  ovary,  and  partly  by  the  open- 
ing of  the  dilated  tube,  whose  extremities  have  contracted  some  adhesions 
with  the  ovarian  tunic. 

The  following  case  of  Dr.  Jackson's  is  justly  quoted  by  M.  Dezeimeris  as 
serving  for  a  type.  A  woman,  aged  thirty-two  years,  was  seized,  in  conse- 
quence of  a  violent  blow  on  the  epigastrium,  with  some  inflammatory  symp- 
toms, to  which  she  speedily  succumbed  ;  at  the  autopsy,  a  large  quantity  of 
blood  was  found  diffused  in  the  abdomen,  and  a  foetus  of  about  ten  weeks 
was  found  enveloped  in  an  enormous  clot ;  the  fundus  uteri  rested  against 
the  pubis,  and  its  cervix  near  the  middle  of  the  sacrum.  This  change  from 
its  natural  position  had  been  produced  by  a  tumor  situated  on  the  left  side 
of  the  womb,  which  tumor  was  formed  by  the  ovary,  the  Fallopian  tube, 
and  the  broad  ligament,  that  had  become  considerably  thickened  and  modi- 
lied  in  their  structure  ;  the  fringed  extremity  of  the  tube  adhered  intimately 
to  the  ovarian  envelope,  and  a  cyst  was  formed  by  these  two  organs,  whose 
distention  by  the  body  contained  therein  had  produced  the  rupture. 

In  another  case,  related  by  Bussieres,  which  seems  to  me  equally  conclu- 
sive, the  tube  on  the  right  side  was  extremely  dilated  at  the  extremity ; 
and  this  dilatation,  which  was  an  inch  in  its  largest  diameter,  extended  for 
rather  more  than  an  inch  and  a  half  in  length,  gradually  diminishing  as  it 
approached  the  womb.     The  portion  of  the  tube  thus  dilated  was  curved 


OF     EXTRA-UTERIXE     PREGNANCY".  589 

jn  itself,  and  en.  braced  nearly  the  whole  ovary,  to  the  menbrane  of  which 
it^as  so  adherent  that  it  could  not  be  separated  without  rupturing  the 
attachments.  An  unctuous,  limpid  fluid  escaped  as  soon  as  it  was  opened, 
and  then  the  ovum  appeared,  which  was  about  the  size  of  a  hazlenut,  and 
was  surrounded  by  the  liquid ;  three-fourths  of  it  had  already  escaped  from 
the  hole  made  in  the  ovary,  so  that  it  no  longer  seemed  to  rest  there ;  yet, 
on  attempting  its  removal,  it  was  found  attached  by  a  hard  pedicle  covered 
with  blood-vessels. 

3.  Tubal  Pregnancy.  —  This  is  the  most  frequent  of  all  the  varieties  of 
extra-uterine  pregnancy ;  which  fact  is  readily  accounted  for  by  the  length 
and  narrowness  of  the  canal,  and  by  the  adhesions  and  morbid  obliterations 
presented  by  its  walls.  Under  such  circumstances,  the  ovule  is  arrested  and 
developed  at  some  point  between  its  abdominal  extremity  and  the  spot  where 
it  enters  the  uterine  parietes ;  and  by  its  continual  growth  distends  enor- 
mously the  fibres  of  the  tube  which  constitute  the  envelope  of  the  foetal 
cyst.  To  the  numerous  cases  of  this  kind  reported  by  Velpeau  and  Dezei- 
meris,  I  might  add  another,  already  published  by  me  in  the  Bulletin  de  la 
SocttU  Anatomique,  but  so  many  examples  are  everywhere  met  with  that  it 
seems  useless  to  reiterate  their  details.  Dr.  Lesouef's  thesis  may  be  advan- 
tageously consulted  on  this  point. 

4.  Interstitial  Tubo-uterine  Pregnancy.  —  In  this  case  the  ovum  is  arrested 
in  that  part  of  the  tube  which  traverses  the  thickness  of  the  uterine  walls ; 
and  although  this  is  its  principal  characteristic,  two  varieties  have  been 
made  of  it,  of  which  we  shall  say  a  few  words. 

In  the  first  variety  the  walls  of  the  tube,  yielding  to  the  distention  occa- 
sioned by  the  development  of  the  ovum,  press  back  the  surrounding  tissue 
proper  of  the  uterus,  but  always  form  the  most  internal  layer  of  the  cyst  in 
which  the  product  of  conception  is  enclosed. 

In  the  second  variety  the  ovule  reaches  that  part  of  the  tube  which  tra- 
verses the  uterine  walls ;  but  having  arrived  there,  it  opens  a  way  through 
the  tubal  parietes,  penetrates  into  the  midst  of  the  fibres  of  the  womb,  and 
thenceforth  has  no  further  relation  with  the  tube ;  hence,  the  surrounding 
cyst  is  formed  by  the  muscular  fibres  of  the  womb  alone. 

After  having  been  once  located  among  the  uterine  fibres,  the  ovum  may 
either  take  an  inward  or  an  outward  direction,  and  consequently  may  become 
seated  near  the  mucous  layer,  or  else  to  the  peritoneal  coat.  In  a  prepara- 
tion belonging  to  M.  Pinel  Grandchamp,  the  volume  of  the  uterus  was  about 
the  same  as  at  six  weeks  or  two  months  of  pregnancy ;  at  its  left  angle,  a 
small  tumor,  slightly  ruptured  behind,  constituted  the  cyst  containing  the 
product  of  conception.  The  tube,  which  passed  behind  it,  communicated 
with  it  by  an  almost  microscopic  orifice,  and  presented  nowhere  any  increase 
of  calibre.     The  cyst  was  about  large  enough  to  contain  an  almond. 

5.  Utero-tubal  Pregnancy.  —  Notwithstanding  the  free  communication 
existing  between  the  tube  and  uterine  cavity,  there  is  no  absurdity  in  the 
supposition  that  the  ovule  may  become  deposited  in  a  little  depression  of 
the  mucous  membrane,  and  there  stop  and  ingraft  itself,  just  at  the  internal 
orifice  of  the  canal.  In  this  case,  phenomena  similar  to  those  of  the  tubo- 
abdominal  gestations  will  arise:   that  is,  the  ovule,  which  may  have  con- 


t>90  PATHOLOGY  OF  PREGNANCY. 

tracted  some  intimate  adhesions  with  this  extremity,  may,  by  its  de\elop- 
ment,  encroach  upon  the  uterine  cavity  itself;  and  I  do  not  hesitate,  there- 
fore, to  consider  this  variety  of  gestation  as  possible. 

It  is  probable  that  certain  singular  cases  described  by  Dezeimeris  under 
the  name  of  utero-tubo-abdominal  pregnancies  belong  properly  to  tubo- 
uterine  pregnancies.  In  this  variety,  examples  of  which  have  been  furnished 
by  Patuna,  Hunter,  and  Hoffmeister,  the  foetus  is  found  in  the  abdominal 
cavity ;  the  cord  leaving  the  umbilicus  enters  the  Fallopian  tube,  traverses 
its  whole  length,  and  is  inserted  in  the  placenta,  which  itself  is  attached  to 
the  internal  surface  of  the  uterus. 

We  explain  them  by  supposing  the  existence  of  a  tubo-uterine  pregnancy 
ending  in  rupture  of  the  tube  with  passage  of  the  foetus  into  the  peritoneum 
whilst, the  placenta  remains  in  the  uterus.  The  cord  traverses  the  tube  in 
its  passage  from  the  foetus  to  its  placenta. 

We  have  not  been  able,  from  the  restricted  limits  of  this  chapter,  to  bring 
forward  a  larger  number  of  cases,  but  sufficient  has  been  said  to  furnish  an 
idea  of  the  importance  that  ought  to  be  attached  to  the  different  varieties 
of  extra-uterine  pregnancy  admitted  by  us. 

The  reader  may  consult  with  benefit  the  article  of  Professor  Velpeau,  in 
the  fourteenth  volume  of  the  Diciionnaire  de  Medecine,  the  learned  memoir 
published  by  M.  Dezeimeris,  in  the  fourth  year  of  the  Journal  des  Connais- 
sances  Medico- Chirurgicales,  and  the  able  articles  of  Messrs.  Breschet,  Me- 
niere, and  Guillemot. 

Other  writers  have  made  fewer  divisions  in  the  classification,  and  the  sub- 
ject lias  been  more  recently  and  thoroughly  studied.  Playfair  makes  four 
classts  (if  extra-uterine  gestation  :  1st,  tubal ;  2d,  abdominal ;  3d,  ovarian  ; 
and  4th,  two  varieties  in  which  an  ovum  is  developed  either  in  the  supple- 
mental^' horn  of  a  bi-lobed  uterus  or  in  a  hernial  sac. 

Prof.  T.  G.  Thomas,  of  New  York,  whose  successful  operations  are  well 
known,  believes  that  "  in  the  commencement  of  its  development  the  impreg- 
nated ovum  never  attaches  itself  to,  nor  draws  its  nourishment  from,  any 
other  parts  than  those  lined  by  the  mucous  membrane  of  the  uterus  or  tubes. 
Knowing,  as  we  do,  the  delicate  and  subtle  connections  which  the  chorion 
establishes  with  the  maternal  tissues,  it  is  certainly  difficult  to  believe  that 
an  impregnated  ovum,  falling  free  into  the  peritoneal  cavity,  or  detained 
within  the  Graafian  vesicle,  can,  with  parts  so  unlike  the  lining  of  the 
uterus,  establish  relations  almost  identical  with  those  which  are  normal." 

Puech,  Annal  de  Gyncec,  July,  1878,  gives  two  varieties  of  ovarian  preg- 
nancy. In  one  the  fetus  has  developed  in  a  vesicle  which  has  remained 
open  after  fecundation,  the  other  in  which  the  vesicle  had  closed.  Most 
of  the  cases  he  regards  as  either  dermoid  cysts,  ovario-tubal  pregnancies,  or 
abdominal  pregnancies  with  placenta  attached  to  the'  ovary. 

The  besl  contribution  that  has  yet  been  made  to  the  subject  is  unquestion- 
ably the  work  of  Parry,  in  a  volume  published  in  1<S7<>.'  According  to  this 
author,  there  are  three  species  of  extra-uterine  pregnancy — tubal,  ovarian, 
and  ventral  or  abdominal — with  varieties  of  each,  as  expressed  in  the  fol- 
lowing schedule  (  loc.  '•/.,  page  49)  : 

1  Extra  uterine  Pregnancy;  Its  Causes,  Species,  Pathological  Anatomy,  Clinical  History, 
etc.,  etc.,  by  John  S.  Parry,  M.  D.     Philadelphia:  1870. 


OF   EXTRA-UTERINE    PREGNANCY. 


591 


Tubal  pregnancy. 


Species.  Varieties. 

Tubo-ovarian  (the  germ  being  arrested  in  the  pavilion,  which  con- 
tracts adhesions  with  the  ovary  i. 

Tubo-abdominal  (germ  arrested  in  the  same  locality.  The  tube 
may  contract  adhesions  with  neighboring  organs.  If  it  does 
not,  the  chorion  may  project  into  the  abdominal  cavity,  with  a 
part  of  its  surface  bare). 

Tubalproper  (germ  arrested  between  the  pavilion  and  thai  por- 
tion of  the  oviduct  which  traverses  the  uterine  wall). 

Tubo-uterine  (germ  arrested  in  that  portion  of  the  tube  which 
passes  through  the  uterus). 

Ovarian  proper  (germ  contained  in  the  ovary;  that  organ  remain- 
ing free  from  adhesions). 
Ovarian  pregnancy.  ■{    Qvari0.tuoai  (germ  contained  in  the  ovary,  which  contracts  adhe- 
sions with  the  pavilion  of  the  tube). 
f  Primary  (ovum  developed   from   the   outset   in   the   perloneal 
cavity). 
Secondary  (development  commences  in  the  tube  or  ovary,  the 
cyst  ruptures,  ovum  escapes,  and  continues  to  live  and  develop 
in  the  peritoneal  cavity). 

From  an  analysis  of  500  cases,  he  gives  the  following  classification  :  "  After 
excluding  all  cases  of  recovery  by  discharge  through  the  abdominal  wall, 
the  alimentary  canal,  or  genito-urinary  tract ;  many  cases  of  recovery  after 
gastrotomy,  in  which  the  variety  of  the  gestation  was  supposed  to  have 
been  determined,  during  the  hurry  and  dread  of  a  critical  operation  ;  all 
cases  of  vaginal  section  which  were  not  fatal,  and  all  cases  in  which  the 
appearances  discovered  at  the  autopsy  were  not  described  with  sufficient  care 
to  warrant  the  deduction  of  correct  conclusions :" 

f  The  ovum  being  developed  in  the  tube  proper        ....  149  j 
The  ovum  being  developed  in  the  pavilion  :  the  tubo-ovarian  and 

Tubal,   -j       tubo-abdominal  varieties 34 

The  ovum  developed  in  uterine  portion  of  tube:  "interstitial"  or 
(_      tubo-uterine  pregnancy 31 


Ventral  or  Abdomi 
nal  pregnancy. 


214 


Ovarian  . 

Abdominal 
Doubtful 


27 

29 

230 


§  1.  Pathological  Changes. 

a.  Product  of  Conception. — In  these  pregnancies  the  ovule  lias  its  proper 
membranes,  the  chorion  and  the  amnion.  I  may  state  that  I  was  utterly 
astonished  to  hear  several  honorable  members  contend,  in  a  recent  discus- 
sion before  the  Academy  of  Medicine-,  that  the  envelope  of  the  ovule,  in  ab- 
dominal gestations,  was  only  composed  of  the  amnios,  and  that  no  chorion 
existed;  for  although,  in  certain  very  old  pregnancies,  the  most  exterior 
fetal  membrane  is  confounded  with  the  walls  of  the  cyst,  it  is  not  fair  to 
conclude  from  thence  that  it  did  not  exist  at  the  commencement. 

The  absence  of  the  chorion  supposes  that  of  the  allantois,  and  withoul 
the  latter  no  circulatory  relations  can  be  established  between  the  embryo  and 
its  mother. 


592  PATHOLOGY  OF  PREGNANCY. 

In  the  so-called  sub-peritoneo -pelvic  gestation,  or  whenever  the  ovule, 
that  was  originally  located  in  the  ovary,  tube,  or  even  the  uterus,  is  trans- 
ferred, after  the  rupture  of  the  cyst  which  inclosed  it,  to  some  part  of  the 
abdominal  cavity,  there  is  besides  a  pseudo-membranous  cyst,  representing 
the  uterine  decidua,  produced  by  the  inflammation  which  the  presence  of 
the  ovule  determines  around  it.  But  this  enveloping  membrane,  the  cyst, 
does  not  exist  in  primitive  peritoneal  pregnancies.  M.  Dezeimeris  thus 
explains  the  latter  circumstance :  When  a  fecundated  ovule  gets  into  the 
abdominal  cavity  immediately  after  quitting  the  ovary,  we  can  readily  be- 
lieve that  a  corpuscle  so  minute,  soft,  and  fragile  could  only  produce  a  very 
slight  irritation  at  the  point  of  arrestation,  and  that  the  extent  of  this  excita- 
tion will  not  pass  beyond  the  limits  of  contact  with  the  little  foreign  body; 
in  a  word,  it  cannot  produce  an  acute  inflammation,  or  extensive  adhesions, 
nor  an  exudation  of  plastic  lymph  sufficient  to  form  an  enveloping  cyst. 
Now,  if  it  has  not  primarily  caused  all  these  derangements,  the  neighboring 
organs  will  not  be  injured  by  its  ulterior  development,  because  they  become 
gradually  habituated  thereto;  and  the  ovule,  having  obtained  a  right  of 
possession,  lives,  grows,  and  presents  to  the  smooth,  polished  surfaces  which 
touch  it,  a  surface  equally  smooth,  polished,  and  moistened  at  their  expense : 
and  not  having  occasion  for  any  other  protecting  envelope,  no  cyst  is  formed. 
But  when  a  voluminous  product  of  conception  suddenly  bursts,  and  its  con- 
tents, placed  at  first  like  it  in  the  tube  or  ovary,  are  transported  to  the  peri- 
toneal cavity,  the  ovule  becomes  there  a  foreign  body,  wounding  and  irri- 
tating the  abdominal  organs  which  are  unaccustomed  to  its  vicinity,  and 
determining  an  acute  inflammation  around  it,  which  results  in  the  exudation 
of  plastic  lymph  ;  this,  by  coagulating,  forms  a  cyst,  and  completely  isolates 
the  foreign  body.  If,  under  these  circumstances,  the  displacement  of  the 
foetus  is  such  that  it  completely  escapes  from  the  amniotic  cavity,  and  sud- 
denly locates  itself  with  its  surrounding  liquid  in  the  midst  of  the  intestinal 
mass,  an  inflammation  occurs,  and  the  cyst  we  have  just  described  forms 
around  it ;  the  new  cyst  then  completely  environs  the  foetus.  But  in  some 
cases  the  displacement  is  not  so  complete  —  the  largest  part  of  the  trunk 
may  still  remain  in  the  amniotic  cavity  after  the  rupture,  \  portion  only 
being  displaced,  and  the  latter  alone  first  determines  an  vnflammation 
around  it,  and  then  the  exudation,  which  is  transformed  into  a  false  mem- 
brane ;  this,  by  uniting  with  the  lacerated  margins,  forms  only  a  part  of  the 
foetal  cyst,  the  remainder  being  constituted  by  the  old  foetal  envelope,  the 
walls  of  the  Fallopian  tube,  for  instance,  in  the  case  of  a  tubal  pregnancy. 
The  same  relations  may  be  established  with  the  membranes  of  the  ovule 
when  the  chorion  and  amnion  are  ruptured  at  an  advanced  period  in  a  case 
of  primitive  abdominal  pregnancy.  For  instance,  in  a  case  cited  by  M. 
Dubois,  the  cyst  that  inclosed  the  foetus  was  formed  of  a  membrane  which 
was  not  altogether  uniform  in  its  structure  and  appearance:  thus,  for  the 
greater  part  of  its  extent,  the  internal  surface  was  of  a  light-brown  color, 
owing  perhaps  to  the  imbibition  of  the  adjacent  liquids,  and  simulating, 
both  to  the  touch  and  sight,  the  aspect  of  the  mucous  membrane  of  the 
small  intestines,  or,  still  better,  the  accidental  membranes  that  occasionally 
line  fistulous  canals ;  while  at  other  points,  those  for  instance  which  were 


OF     EXTRA-UTERINE     PREGNANCY.  5Hi^ 

near  the  circumference  of  the  placenta,  and  on  the  largest  part  of  this  sur- 
face, the  cyst  was  more  smooth  and  polished ;  presenting,  in  fact,  the  ordi- 
nary appearance  of  the  amnion. 

The  cyst  was  simple,  and  about  a  fourth  of  a  line  in  thickness  at  the  part 
where  it  exhibited  the  brown  and  villous  character  above  alluded  to;  but 
on  the  contrary,  where  the  surface  was  smooth  and  polished,  it  evidently 
consisted  of  two  membranes  (the  chorion  and  the  amnion.) 

In  all  cases,  numerous  and  large  vessels  form  in  the  walls  of  the  cyst 
whose  rupture  it  is  evident  must  give  rise  to  hemorrhage,  which  very  often 
proves  fatal  to  the  mother. 

When  an  extra-uterine  pregnancy  is  somewhat  prolonged,  these  envelopes 
are  sometimes  destroyed,  being  perforated  with  fistulous  canals,  communi 
eating  directly  with  the  intestinal  canal,  vagina,  bladder,  uterus,  or  an  ex 
ternal  abscess.  At  times,  the  destruction  of  the  cyst  is  partial,  at  others 
complete ;  so  much  so,  indeed,  as  to  leave  in  certain  cases  no  vestiges  of  its 
former  existence;  on  the  other  hand,  the  envelopes  sometimes  undergo 
osseous  or  cretaceous  transformations,  which  may  convert  them  into  solid 
shells.  As  a  general  rule,  the  foetus  exhibits  nothing  peculiar  in  its  devel- 
opment :  for  example,  in  several  cases  studied  anatomically  a  long  time  after 
the  term  of  pregnancy,  the  osseous  system  appeared  to  have  a  better  devel- 
opment than  in  the  ordinary  child  of  nine  months.  The  existence  of  several 
teeth  has  frequently  been  noticed,  or  else  traces  of  the  eruption  of  these  little 
bones,  which  would  seem  to  afford  an  indication  that  the  foetus  continued  to 
live  and  grow  beyond  the  ordinary  term  of  gestation. 

The  most  common  of  the  numerous  alterations  which  it  may  undergo,  ia 
the  putrescent  dissolution  of  its  soft  parts,  from  macerating  in  a  compound 
of  amniotic  liquor,  blood,  and  pus  ;  the  separation  of  the  various  pieces  of  its 
skeleton,  and  their  discharge  through  the  divers  routes  just  mentioned.  At 
other  times,  it  seems  to  have  undergone  a  kind  of  mummification,  a  com- 
plete drying-up.  Again,  in  other  cases,  all  the  tissues  appear  to  be  trans- 
formed into  an  osseous  or  cretaceous  substance,  or  into  one  resembling 
adipocire, — and  here,  it  is  doubtless  unnecessary  to  add,  it  is  no  longer 
possible  to  discover  any  trace  of  the  foetal  membranes. 

b.  Tissues  of  the  Mother.  —  Some  very  large  vascular  canals  are  seen  to 
develop  themselves  in  those  parts  where  the  ovum  is  attached,  however 
devoid  of  blood-vessels  they  might  have  been  previously  ;  and  several  great 
veins  are  found  to  ramify  under  the  peritoneum  towards  the  circumference 
of  the  placental  attachment ;  and  where  the  ovary  or  the  tube  happens  to  be 
the  seat  of  pregnancy,  it  presents  a  soft  tissue,  apparently  fungous  in  char- 
acter, and  impregnated  with  blood. 

The  womb  does  not  continue  so  indifferent  to  the  advancement  of  the 
extra-uterine  pregnancy  as  might  be  supposed  ;  for  its  volume  increases  in  a 
remarkable  degree,  the  tissues  become  softer,  and  the  mucous  membrane 
hypertrophied  and  more  vascular,  so  as  to  form  from  the  outset  a  true 
decidua.  M.  Velpeau,  however,  disputes  this  last  assertion  ;  but  I  have 
endeavored  to  refute  his  opinion  in  the  Bulletin  de  la  SocUti  Anatomique 
/C!ept.  1836),  to  which  the  reader  is  referred. 

Phis  hypertrophy  of  the  uterine  mucous  membrane  is  of  short  duration. 
38 


594  PATHOLOGY    OP    PREGNANCY. 

For,  as  the  ovum  does  not  enter  the  uterus,  it  has  nu  »ffice  to  perform. 
and,  therefore,  like  every  other  useless  organ,  becomes  atrophied,  loses  its 
vascularity,  and  in  a  few  months  has  returned  to  its  usual  condition.  A 
gelatinous  substance,  a  kind  of  thick,  ropy  mucus,  is  also  frequently  found 
in  the  neck  of  the  uterus;  but  when  the  pregnancy  has  advanced  beyond 
term,  the  womb  gradually  regains  its  natural  condition.  Finally,  in  certain 
cases,  the  calibre  of  the  Fallopian  tube  has  been  found  obliterated  at  some 
part  of  its  length. 

§  2.  Symptoms  and  Diagnosis  of  Extra-Uterine  Pregnancy. 

During  the  early  months  it  is  exceedingly  difficult  to  recognize  the  exist- 
ence of  an  extra-uterine  pregnancy  ;  for  the  modifications  which  then  occur 
in  the  size,  form,  and  consistence  of  the  body  and  neck  of  the  uterus,  will 
certainly  lead  to  error,  and  give  rise  to  the  belief  of  a  true  gestation.  With 
regard  to  the  menstruation  and  the  lacteal  secretion,  no  constant  rule  is 
observed.  Sometimes  the  menses  continue  to  appear  ;  at  others,  they  do  not. 
In  some  instances  this  function  is  not  re-established,  even  after  the  period 
when  the  accouchement  should  have  taken  place ;  and  similar  variations  are 
met  with  in  the  secretion  of  milk.  Again,  menstruation  has  been  known 
never  to  appear  during  an  extra-uterine  pregnancy  which  lasted  more  than 
thirty  years,  while  the  lacteal  flow  continued  throughout  the  whole  of  that 
time. 

There  are,  likewise,  some  abdominal  pains,  at  a  period  not  very  distant 
from  the  date  of  conception,  more  or  less  analogous  to  the  uterine  pains,  and 
at  times  a  constant,  fixed,  circumscribed  one  in  the  pelvis,  groin,  or  umbilical 
region.  (The  woman  whose  preparation  I  presented  to  the  Anatomical 
Society,  had  on  this  account  been  treated  for  a  partial  peritonitis.)  Not  un- 
frequently  there  is  an  inability  to  lie  upon  one  side.  When  the  tumor, 
whilst  still  small,  falls  into  the  lesser  pelvis,  it  pushes  the  uterus  forward, 
the  neck  being  directed  in  front  and  quite  high  behind  the  pubis.  This 
displacement  of  the  neck  of  the  womb,  together  with  the  presence  of  a  large 
tumor  occupying  the  excavation  posteriorly,  and  the  dysuria  occasioned  by 
the  pressure  made  upon  the  neck  of  the  bladder,  has  been  mistaken  for 
retroversion.     Several  examples  of  this  error  are  mentioned  by  Burns. 

At  a  later  period  the  tumor  rises  above  the  superior  strait.  The  motions 
of  the  child  are  felt  at  the  usual  time,  but  they  appear  to  be  more  super- 
ficial, and  are  generally  felt  on  one  side  only. 

The  labor-pains  come  on  at  the  natural  term,  or  at  the  seventh  month,  or 
even  sooner,  generally  lasting  for  three  or  four  days,  but  occasionally  much 
longer;  and,  should  the  pregnancy  be  unusually  prolonged,  they  are  apt  to 
return  at  varied  intervals,  and  again  pass  off. 

Schmidt  reports  a  case  where  the  gestation  lasted  three  years,  within 
which  period  the  labor-pains  were  renewed  eight  times,  and  on  each  occasion 
continued  for  several  weeks. 

In  another  gestation,  of  ten  years'  duration,  the  pains  returned  annually 
at  the  period  corresponding  to  the  term  of  pregnancy. 

These  pains  are  not  produced  by  contraction  of  the  walls  of  the  cyst,  as 
many  have  stated ;  because,  excepting  the  cases  of  tubal  and  interstitial 


OF    EXTRA-UTERINE    PREGNANCY.  595 

pregnancy,  they  never  contain  any  muscular  fibres,  and  hence  we  must 
search  for  the  cause  in  the  uterus  itself;  for  the  great  development  exhibited 
by  this  organ,  and  the  mucous  and  albuminous  matters  inclosed  in  its  cavity, 
the  expulsion  of  which  requires  some  contractions,  sufficiently  account  for 
the  pains  experienced  by  the  patients.  But  it  is  exceedingly  difficult  to 
explain  in  a  satisfactory  manner  their  frequent  coincidence  with  the  usual 
term  of  gestation. 

The  physical  signs  which  require  our  notice  are,  the  changes  in  the  uter- 
ine body  and  neck,  just  indicated,  the  more  or  less  irregular  development 
of  the  belly,  and  the  possibility,  in  some  cases,  of  distinguishing  two  tumors, 
one  being  the  uterus,  while  the  other  is  formed  by  the  abnormal  cyst. 

In  the  sub-peritoneo-pelvic  variety,  the  product  of  conception,  by  occupy- 
ing the  pelvic  excavation,  displaces  and  compresses  the  organs  there  situated, 
the  vagina  and  rectum,  for  instance,  and  pushes  them  to  one  side.  The 
vagina  and  rectum  are  found  to  be  obstructed  by  a  tumor  situated  between 
them,  and  frequently  the  different  parts  of  the  foetus  may  be  detected  by 
the  vaginal  touch. 

The  foetus  seems  to  be  much  nearer  the  surface  in  the  abdominal  preg- 
nancy than  in  either  of  the  other  varieties,  hence  its  motions  are  more  easily 
perceived,  and  are  more  distressing  to  the  mother,  and  the  forms  of  the 
different  parts  more  clearly  distinguishable.  Besides,  the  rounded  and 
regularly  circumscribed  tumor  formed  by  the  uterus  in  a  normal  gestation 
is  not  present. 

In  the  tubal  and  ovarian  varieties,  says  Baudelocque,  the  foetal  movements 
should  be  less  vague,  and  its  limbs  more  retracted.  The  body  of  the  uterus 
is  associated  with  the  tumor  formed  by  the  foetal  cyst,  and  can  neither  be 
separated  nor  readily  distinguished  from  it. 

I  have  thus  brought  forward  the  various  signs  by  which  authors  endeavor 
to  detect  the  different  species  of  extra-uterine  gestation,  although  they  have, 
in  my  estimation,  but  little  practical  importance ;  nor  do  I  see  that  auscul- 
tation itself  could  render  us  much  service  in  determining  the  diagnosis. 

I  ought  to  observe  that  the  possibility  of  a  fresh  fecundation  is  a  feature 
common  to  all  the  varieties  of  extra-uterine  pregnancy. 

Perhaps  it  may  be  serviceable  to  note  that  the  vacuity  of  the  uterus  might 
be  detected  by  the  touch.  Very  frequently  its  habitual  position  will  be 
changed  by  the  pressure  of  the  tumor,  more  especially  when  the  latter  occu- 
pies the  excavation,  and  urges  it  against  some  part  of  the  pelvic  walls. 

Finally,  when  by  the  usual  signs  we  have  become  assured  of  the  existence 
of  pregnancy,  and  we  suspect  that  it  is  extra-uterine,  the  diagnosis  will  be 
reduced  to  a  certainty  if  we  can  determine  the  capital  point,  which  is,  that 
the  uterus  is  empty.  Now  we  have  just  seen  that  this  knowledge  can  be 
arrived  at  by  means  of  palpation  and  the  touch.  Professor  Stoltz  was  the 
first  to  use  the  uterine  sound  for  the  same  purpose ;  but  it  will  be  readily 
understood  why  great  prudence  should  be  exercised  in  deciding  to  employ 
it.  In  case  of  a  normal  pregnancy,  the  sound  would,  in  fact,  be  almost 
sure  to  produce  abortion,  and  then  the  mistake  would  be  irreparable.  The 
use  of  the  uterine  sound  is  more  rational  and  truly  useful  when  the  question 
to  be  decided  is,  whether  there  be  an  extra-uterine  pregnancy  or  a  fibroin 
tumor  of  the  uterus. 


596  pathology    of    pregnancy. 

§  3.  Progress  axd  Termination. 

It  is  but  rarely  that  an  extra-uterine  pregnancy  is  prolonged  beyond  the 
fourth  or  fifth  month  ;  for  generally  the  walls  of  the  cyst  give  way,  in  con- 
sequence of  their  distention,  before  it  has  had  time  to  become  very  large. 
Sometimes,  however,  the  fetal  envelopes  resist  the  pressure  to  which  they 
are  subjected,  and  if  the  fetus  itself  do  not  perish  through  want  of  nourish- 
ment, or  by  some  accidental  disease,  its  development  may  progress  until 
term,  and  it  may  even  live  for  some  time  after  the  expiration  of  the  ninth 
month.  Such  is  reported  by  Dr.  Grossi  to  have  been  the  case  with  a  lady, 
who,  in  all  probability,  carried  an  extra-uterine  fetus,  whose  motions  were 
perceived  clearly  by  himself  and  several  consulting  physicians,  through  a 
space  of  fourteen  months.  Usually,  the  child  perishes  either  before  or 
shortly  after  the  term  of  pregnancy  ;  and  we  shall  now  proceed  to  point  out 
the  possible  consequences  of  its  retention. 

A.  Rupture  of  the  Cyst. —  When  left  to  itself,  an  extra-uterine  pregnancy 
will  generally  terminate  in  a  rupture  of  the  cyst ;  but  the  time  and  conse- 
quences thereof  are  very  variable.  Were  we  to  class  these  pregnancies 
according  to  the  frequency  of  the  rupture,  and  the  early  period  of  its  occur- 
rence, they  would  stand  as  follows :  the  tubo-interstitial,  tubal,  and  ab- 
dominal. 

It  is  very  rare  for  the  period  of  the  rupture  to  extend  beyond  the  middle 
term  of  pregnancy,  except  in  the  last  variety.  Dr.  Lesouef  very  properly 
dwells  on  the  tendency  of  tubal  pregnancies  to  rupture  at  a  very  early 
stage  of  gestation.  According  to  the  same  author,  and  to  M.  Bernutz,  his 
master,  if  the  rupture  of  the  tube  occurs  at  one  of  the  points  where  it  is 
covered  by  the  peritoneum,  the  consequent  effusion  takes  place  into  the 
peritoneal  cavity ;  this,  however,  is  not  necessarily  so,  because  the  tube 
might  give  way  at  its  adherent  edge,  and  allow  the  ovule  to  slip  between 
the  two  layers  of  the  broad  ligaments.  In  this  case,  the  result  would  be  a 
true  consecutive  sub-peritoneo-pelvic  pregnancy. 

The  rupture,  which  is  usually  spontaneous,  always  gives  rise  to  exceed- 
ingly grave  phenomena,  which  may  be  described  as  the  primitive  and 
secondary  consequences.  Thus,  the  patient  at  once  suffers  from  violent 
pains  for  several  hours ;  then,  after  a  pain  which  is  much  stronger  than  all 
the  others,  a  perfect  calm  comes  on.  The  abdomen  sinks,  or  becomes  flat- 
tened, and  the  former  tumor  disappears ;  a  gentle  and  equal  heat  spreads 
over  the  abdominal  cavity,  and  if  the  pregnancy  is  well  advanced,  the 
patient  feels  as  though  a  voluminous  body  had  been  suddenly  displaced ; 
the  skin  loses  its  natural  hue,  faintings  come  on,  the  pulse  is  small  and  con- 
tracted, a  cold  sweat  covers  the  whole  body,  and  death  frequently  follows, 
because  the  rupture  of  the  cyst  is  often  the  immediate  cause  of  a  hemorrhage 
that  speedily  proves  fatal.  Should  any  circumstance  whatever  arrest  the 
hemorrhage,  the  first  symptoms  that  follow  the  displacement  of  the  product 
of  conception,  and  the  transference  of  the  waters,  blood,  or  even  the  fetus 
itself,  to  parts  not  accustomed  to  such  contact,  are  those  of  a  vei  y  violent 
peritonitis.  The  patient  generally  dies,  though  sometimes  she  is  able  to 
resist  the  violence  of  the  first  inflammatory  symptoms,  in  which  case  the 
course  of  the  ditease  differs  from  that  time,  according  to  whether  the  dcbria 


OF   EXTRA-UTERINE    PREGNANCY.  597 

of  the  pregnancy  are  to  be  inclosed  in  a  cyst  of  new  formation  for  the  re- 
mainder of  the  patient's  life,  or  whether  they  are  to  be  eliminated  in  various 
ways.  In  the  first  case,  the  foetus  may  undergo  all  the  transformations 
described  under  the  head  of  the  pathological  anatomy  ;  and  in  the  second, 
the  symptoms  vary  with  the  manner  in  which  the  elimination  is  effected. 

B.  Prolonged  Retention  of  the  Cyst. — As  we  have  already  stated,  the 
peculiarities  of  extra-uterine  pregnancy,  when  the  integrity  of  the  cyst 
allows  the  development  of  the  foetus  to  proceed  until  term,  and  even  some- 
what beyond  it,  we  shall  not  reconsider  it.  We  would,  however,  add,  that 
in  some  cases  the  disorders  of  the  general  health,  produced  by  the  develop- 
ment of  these  abnormal  pregnancies,  have  been  so  great  as  to  prove  fatal, 
without  there  being  any  discoverable  lesion  to  account  therefor.  Thus, 
says  M.  Jacquemier,  the  autopsy  reveals  neither  rupture  of  the  cyst,  nor  a 
trace  of  hemorrhage,  peritonitis,  nor  process  of  elimination  going  on  in  the 
cyst :  the  unfortunate  sufferers  appearing  to  have  succumbed  under  a  kind 
of  exhaustion  of  vital  power. 

The  development  of  the  cyst  ceases  with  the  life  of  the  foetus,  the  circula- 
tion in  its  walls  becomes  feebler,  the  vessels  which  maintain  the  connections 
necessary  to  the  support  of  the  ibetal  life,  gradually  become  atrophied,  and 
even  in  great  part  obliterated;  so  that  the  foetus  and  its  envelopes  are 
thenceforth  a  foreign  body  within  the  organism  of  the  mother.  Occasion- 
ally, the  latter  becomes  accustomed  to  their  presence;  for  some  women  carry 
a  foetal  cyst  for  many  years  without  their  health  appearing  to  be  much 
injured  thereby  :  we  have  mentioned  what  transformations  the  foetus  and  its 
envelopes  are  liable  to  undergo  in  such  cases.  Sometimes,  however,  the 
weight  of  the  tumor,  and  the  pressure  which  it  exerts  upon  the  neighboring 
parts,  disturb  the  general  functions  so  seriously  as  to  make  the  female  de- 
mand earnestly  to  be  relieved  of  the  cause  of  her  suffering  by  an  operation. 

Whether  the  tumor  be  the  cause  of  acute  pain  to  the  woman  or  not,  it  is 
likely,  after  the  lapse  of  an  indeterminate  period,  to  become  the  seat  of  an 
inflammation,  which  extends  rapidly  to  the  neighboring  parts.  In  conse- 
quence of  this  inflammation,  which  may  progress  with  greater  or  less  rapidity, 
adhesions  are  contracted  between  the  walls  of  the  cyst  and  the  parts  adja- 
cent ;  ulceration  begins  at  the  points  of  adhesion,  perforation  follows  with 
the  formation  of  communications  between  the  cavity  of  the  cyst  and  that 
of  one  of  the  neighboring  organs,  or  with  the  exterior,  in  case  the  abdominal 
walls  be  invaded  by  the  ulceration. 

The  foetal  debris  find  their  way  to  the  exterior,  at  times  by  the  bladder, 
rectum,  vagina,  and  even  the  stomach,  at  others  by  means  of  an  abscess 
opening  into  the  perineum,  or  through  the  anterior  abdominal  parietes. 
Furthermore,  since  these  latter  communications  are  common  to  all  kinds  of 
extra-uterine  pregnancies,  we  can  understand  that  the  situation  of  the  foetus 
in  the  sub-peri toneo-pelvic  variety,  which,  as  before  stated,  is  the  most  deeply 
engaged  in  the  excavation,  will  render  its  expulsion  by  the  vagina  or  rectum 
more  frequent  than  in  the  others. 

Most  generally  some  one  of  the  above-mentioned  organs  serves  as  an  ex- 
cretory c%nal,  but  in  certain  cases  several  of  them  are  simultaneously  attacked 
b}  the  adhesive  inflammation;  of  course,  ulceration  and  perforation  soon 


098  PATHOLOGY  OF  PREGNANCY. 

follow  ;  and  the  wreck  of  the  foetus  escapes  at  once  by  the  anus,  the  vagina, 
and  through  a  fistulous  opening  in  the  abdominal  walls. 

This  expulsion  greatly  endangers  the  mother's  life  —  for  very  often  the 
inflammation  and  suppuration  of  the  cyst,  by  spreading  to  neighboring 
parts,  exhausts  the  patient,  and  sooner  or  later  she  succumbs.  In  the  more 
fortunate  cases,  the  sac  is  gradually  emptied,  cleansed,  and  contracted,  the 
suppuration  ceases,  and  the  wound  cicatrizes,  or  at  least  becomes  a  simple 
fistulous  ulcer. 

The  long-continued  suppuration,  and  consequent  exhaustion  of  the  patient's 
st  rength,  will  always  render  a  complete  expulsion  of  the  foreign  bodies  highly 
desirable,  for  nothing  else  will  put  an  end  to  the  suppuration  and  allow  the 
fistulas  to  close.  Unfortunately,  the  hair,  teeth,  and  pieces  of  bony  substance 
adhere  very  strongly  to  the  walls  of  the  cyst,  in  which  they  seem  to  be  im- 
bedded, and  are  detached  with  difficulty  ;  yet  it  is  very  necessary  to  be  care- 
ful not  to  use  too  much  force  for  their  extraction,  lest  the  walls  of  the  cyst 
should  be  torn,  and  an  opening  made  between  it  and  the  cavity  of  the  peri- 
toneum, rendering  liable  the  occurrence  of  a  quickly  fatal  peritonitis.  The 
interference  of  the  surgeon  should  be  restricted  to  the  dilatation  of  all  the 
openings  and  fistulous  passages  by  means  of  compressed  sponge,  to  cleansing 
injections  within  the  cyst,  and  to  the  withdrawal,  by  means  of  forceps,  of 
the  completely  detached  portions  of  bony  matter  which  present  themselves  at 
the  openings.  In  no  case,  I  repeat,  should  any  effort  be  made  to  detach  the 
strongly  adherent  portions. 

§  4.  Causes. 

Nothing  can  oe  more  obscure  than  the  causes  of  extra-uterine  pregnancy, 
although  numerous  facts  would  seem  to  prove  that  the  action  of  terror,  coin- 
ciding with  the  time  of  fecundation,  may  produce  such  an  effect  as  to  prevent 
the  impregnated  ovule  from  being  ulteriorly  transported  into  the  uterus ; 
but  notwithstanding  the  high  authority  of  those  who  have  adopted  this  doc- 
trine, it  does  not  appear  to  be  admissible,  since  the  ovule  does  not  abandon 
the  ovary  at  the  moment  of  conception,  but  several  days  after  or  even  several 
days  before  this  event. 

M.  Dezeimeris  brings  forward  one  case  that  seems  to  prove  that  a  blow  on 
the  hypogastrium  a  short  time  after  a  fruitful  coition  may  be  the  cause  of 
this  anomaly,  though  I  should  rather  refer  it  to  a  particular  disposition  of 
the  mother's  organs.  When,  indeed,  we  consider  the  narrowness  of  the  tubal 
canal,  we  can  readily  conceive  that  any  deviations,  even  slight  ones,  of  the 
Fallopian  tube,  any  paralysis  or  spasm,  an  excess  or  defect  of  length,  an 
engorgement,  the  swelling  and  ulceration  of  the  mucous  membrane,  or  hard- 
ening of  its  pavilion,  or  any  retraction  at  the  internal  orifice;  in  one  word, 
all  the  anomalies  and  alterations  described  by  authors  may  take  place  there, 
and  give  rise  to  it.  1  myself  have  had  an  opportunity  of  observing  two 
cases  i  reported  in  the  Bulletin  de  la  SociHe  Anatomique)  in  which  the  tube 
was  obliterated  between  the  point  where  the  ovule  was  developed  and  the 
internal  orifice  of  this  canal.1 

1  Tin'  obliteration  of  the  tube  in  the  case  referred  to  is  so  remarkable  an  occurrence, 
thai  I  endeavored  to  learn,  by  referring  to  various  authors,  whether  similar  cases  had 


OF     EXTRA-UTERINE     PREGNANCY.  599 

Finally,  if  we  take  into  consideration  the  singular  anomaly  tlescri  ted  bv 
M.  G.  Richard  (see  page  86),  we  may  suppose  that  the  fecundated  ovule 

been  reported.  Most  of  them  have  not  observed  the  state  of  permeability  or  imper- 
meability of  the  tube;  others,  on  the  contrary,  have  given  their  attention  to  this  point 
Thus,  Smellie  (vol.  ii.  p.  77)  quotes  an  observation  of  Dr.  Fern,  in  which  an  oblitera- 
tion, or  rather  an  excessive  retraction  of  the  tube  was  described.  In  the  memoir  of 
M.  Breschet,  on  interstitial  pregnancy,  I  found  several  instances  where  the  oblitera 
tion  of  the  uterine  orifice  was  also  noted.  M.  Mayer  communicated  a  case  to  M 
Breschet,  where  the  foetus  was  developed  in  that  part  of  the  tube  which  traversed  the 
substance  of  the  uterine  walls;  M.  Mayer  further  remarks,  that  the  right  tube  was 
dilated  at  its  fringed  extremity,  contracted  in  the  uterine  portion,  and  was  completely 
obliterated  at  about  three  lines  from  the  uterus;  the  left  one,  in  which  the  ovule  was 
developed,  was  permeable  as  far  as  the  morbid  mass,  but  from  this  point  to  the  uterus 
the  canal  ceased.  He  adds:  It  is  very  probable  that  an  induration  of  the  uterine 
substance  formerly  existed  at  the  insertion  of  the  left  tube,  which  caused  the  occlusion 
of  its  orifice,  and  fumislted  an  obstacle  to  the  passage  of  the  ovule. 

M.  Schmidt  reports  that  in  an  example  of  interstitial  pregnancy,  of  six  weeks,  the 
internal  orifice  of  the  right  tube  was  completely  closed.  (The  ovule  was  developed 
on  the  right  side  of  the  womb.) 

M.  Meniere  {Archives,  June,  1826)  furnishes  a  case  of  interstitial  pregnancy  located 
in  the  left  cornua,  and  he  says  the  left  tube  was  impermeable  at  its  internal  part. 

M.  Gaide,  in  a  similar  instance  (Journal  Hebdomadaire,  t.  i.),  ascertained  that  the 
right  tube  had  no  uterine  orifice. 

Another  case  is  reported  in  the  Archives  of  a  mortal  hemorrhage  produced  by  tubal 
pregnancy.  The  author  adds:  "  The  left  tube  (the  ruptured  one)  formed  a  consistent 
membranous  sac,  and  its  free  extremity  embraced  the  whole  ovary;  below  the  dilata- 
tion and  in  the  uterine  portion,  the  canal  was  completely  obliterated  in  such  a  manner 
that  it  was  wholly  impossible  to  reach  the  uterus  through  it." 

From  all  which  it  follows,  as  a  natural  consequence,  that,  contrary  to  the  opinion 
generally  received,  it  is  not  necessary  for  the  sperm  to  pass  successively  through  the 
uterus  and  the  Fallopian  tube,  so  as  to  approach  and  fecundate  the  ovule;  and,  further, 
this  conclusion  permits  the  adoption  of  certain  facts  which  have  been  rejected  as  im- 
probable; for  we  can  explain  by  it  how,  in  some  females,  there  may  happen  to  be  a 
complete  occlusion  of  the  os  tincae  at  the  period  of  labor;  how,  in  others,  the  fecun- 
dation has  taken  place  without  a  proper  introduction  of  the  membrum  virile,  the  phys- 
ical proofs  of  virginity  even  remaining  at  the  time  of  labor. 

Perhaps  comparative  anatomy  might  throw  some  light  on  the  question  before  us: 
thus,  in  certain  mammalia,  such  as  the  hog,  cow,  &c,  the  Fallopian  tube  is  not  the 
only  canal  that  affords  a  passage  to  the  sperm;  for  M.  Gartner,  of  Copenhagen,  has 
announced  the  existence  of  a  particular  duct  in  these  animals,  which  extends  from  the 
external  parts  through  the  substance  of  the  broad  ligaments.  In  1820  he  came  to 
Paris,  and,  conjointly  with  M.  de  Blainville,  made  some  new  researches  on  this  point, 
the  results  of  which  the  French  naturalist  has  communicated  to  the  public  in  the  JJul- 
letin  de  la  Societe  Philomatique,  t.  9,  p.  100,  182G.  The  latter  Bays,  that  it'  the  vagina  of 
a  young  sow  be  carefully  examined,  a  particular  canal  will  be  discovered,  having  its 
external  orifices  on  each  side  of  the  meatus  urinarius,  and  running  through  the  iiius 
cular  fibres  of  the  vagina;  it  becomes  contracted  near  the  neck  of  the  uterus,  but  does 
not  the  less  continue  in  the  uterine  tissue.  This  canal  at  fust  follows  the  body  of  the 
womb,  then  abandons  it,  and  runs  in  the  substance  of  the  broad  ligament  parallel  to 
the  corresponding  cornua  and  close  to  the  origin  of  the  Fallopian  tube,  where  it  in 
lost  by  seeming  to  spread  out,  or  to  subdivide  into  two  or  three  filaments,  which  can 
scarcely  be  distinguished  from  the  vessels,  and  more  especially  from  the  proper  tissue 
of  the  broad  ligament. 

M.  de  Blainville  says  he  has  searched  in  vain  for  similar  canals  in  women,  but  he 
fias  not  met  with  anything  of  the  kind.  Analogy,  however,  renders  their  existence 
probable  in  the  human  species;  and  this  probability  becomes  still  stronger  from  the 


600 


PATHOLOGY    OF    PREGNANCY. 


might,  in  its  progress  along  the  tube  towards  the  uterus,  escape  through 
one  tit'  those  accidental  openings,  and  so  fall  into  the  abdominal  cavity. 

account  of  a  case  communicated  by  M.  Baudelocque  to  the  Acad&nie  de  MeMecine 
(Arch.  de  Mid.  L826),  as  a  unique  anomaly  in  the  science,  although  it  is  a  very  sin- 
gular fact  that  Dulaurens,  according  to  the  report  of  Mauriceau  i  Traiti  des  Maladies 
des  Femmes  Grosses,  p.  12,  t.  1).  had  several  times  observed  that  the  lube,  after  arriving 
at  the  angle  of  the  uterus,  separated  into  two  distinct  canals,  the  larger  and  shorter 
of  which  was  inserted  into  the  fundus  uteri,  while  the  other,  being  narrower  and  lunger, 
terminated  at  the  neck,  near  its  internal  orifice. 

De  Graaf  (Opera  Omnia,  p.  212)  thought  he  had  found  canals  in  women  similar  to 
those  described  by  M.  Gartner  as  existing  in  certain  mammalia. 

Lastly,  Mad.  Boivin  declares  she  has  met  with  cases  analogous  to  the  bifurcated 
canal  of  M.  Baudelocque.  Hence,  in  these  examples  at  least,  there  is  good  ground 
for  supposing  that  a  conception  may  occur,  even  when  the  internal  orifice  of  the  tube 
is  wholly  obliterated. 

Now  if,  as  Mauriceau  and  Dulaurens  say  (whose  researches  the  modern  authors 
seem  to  have  entirely  overlooked),  such  anomalies  were  found  at  a  period  when  dissec- 
tions wen-  much  more  rare  than  at  the  present  time,  we  may  conclude  that,  if  the 
writers  of  our  own  day  have  not  realized  that  disposition,  it  is  because  their  efforts 
are  not  directed  to  the  same  end. 

Among  the  causes  of  extra  uterine  pregnancy  mentioned  by  Parry,  are  pelvic  in- 
flammations, peri-  and  para-metritis,  which  produce  constriction  and  displacement  of 
the  uterine  appendages,  peritonitis  following  previous  confinement,  pelvic  abscess  open- 
ing into  the  vagina.  Numerous  cases  of  extra-uterine  pregnancy  are  cited  in  which 
previous  inaptitude  for  conception,  either  primarily  or  after  they  have  borne  one  or 
more  children,  existed. 

Hernia  of  some  portion  of  the  internal  genital  organs,  uterine  displacements,  an 
unhealed  section  of  the  uterus  made  in  the  operation  of  gastro-hysterotomy,  a  fistula 
through  the  cicatrix  of  the  neck  of  a  uterus,  in  which  all  of  the  body  and  part  of  the 
neck  were  removed  on  account  of  a  fibroid  tumor,  are  also  mentioned. 


Fig.  92a. 


The  illustration  given  above  of  bifurcation  of  the  Fallopian  tube,  serves  to  explain 
a  number  of  cases  referred  to  as  tubo-uterine ;  a  notable  instance  occurring  in  the 
practice  of  Dr.  Hodge  is  mentioned  by  Parry  on  page  2<i*5.  A  case  reported  by  Dr. 
Gilbert,  in  the  Boston  Medical  and  Surgical  Journal,  March,  1877,  as  quoted  by  Lusk, 
page     1  I,  belongs  to  this  exceedingly  interesting  variety. 


OF    EXTRA-UTERINE    PREGNANCY.  601 

§  5.  Treatment. 

It  is  evident  that  no  operation  could  be  attempted  in  the  earlier  months 
of  pregnancy,  even  if  we  should  be  fortunate  enough  to  ascertain  with  cer- 
tainty that  the  ovule  was  not  developed  in  the  uterus.  Frequent  copious 
bleedings  should  be  resorted  to  in  such  cases,  for  the  double  purpose  of 
causing  the  death  of  the  foetus  and  of  preventing  too  great  a  determination 
of  blood  towards  the  point  at  which  the  ovum  is  being  developed. 

It  seems  clear  to  me  that  not  only  does  the  constantly  increasing  weakness 
of  the  walls  of  the  cyst,  but  also  the  local  congestions  so  common  during 
pregnancy,  contribute  to  render  rupture  of  the  cyst  more  frequent. 

Venesection,  practised  within  the  limits  authorized  by  the  general  health 
of  the  patient,  will  be  the  more  indicated  here,  as  its  unfavorable  influence 
on  the  child's  life  is  not  to  be  dreaded,  since  its  death  is  the  most  fortunate 
event  that  could  occur. 

This  latter  result  may  be  obtained  by  passing  electric  shocks  through 
the  cyst.  Dr.  J.  G.  Allen,  of  Philadelphia,  succeeded  twice  in  causing 
the  death  of  the  foetus  by  means  of  the  Faradaic  current.  He  applied  one 
pole  of  an  ordinary  electro-magnetic  machine  to  the  tumor  in  the  vagina 
through  a  glass  speculum,  the  other  placed  upon  the  abdomen  over  the  foe- 
tal cyst. 

Drs.  Lovering  and  Landis  reported  a  successful  case  in  1877.  since  which 
time  others  have  been  reported  by  Reeve,  H.  P.  C.  Wilson,  and  Lusk.  in 
the  case  reported  by  Lusk,  he  succeeded  after  the  tenth  application,  treat- 
ment beginning  at  the  end  of  the  tenth  week,  dating  from  the  last  men- 
struation. 

Prof.  T.  G.  Thomas  reported  in  the  New  York  Med.  Jour.,  June,187">,  a  case 
of  tubal  pregnancy  of  three  months  treated  successfully  by  cutting  into  the 
sac  through  the  vaginal  wall  by  means  of  the  platinum  knifeof  the  galvano- 
caustic  battery.  There  was  no  blood  lost  until  efforts  to  remote  the  placenta 
by  gentle  traction  and  detachment  brought  on  a  severe  hemorrhage.  A 
little  over  half  of  the  placenta  was  removed  when  he  was  obliged  to  inject 
a  solution  of  persulphate  of  iron.  Symptoms  of  septicaemia  set  in  on  the 
fourth  day,  which,  however,  yielded  to  constantly-repeated  injections  into 
the  sac  of  carbolized  water.  The  remaining  portion  of  the  placenta  came 
away  spontaneously  on  the  fifteenth  day. 

The  operation  devised  by  Dr.  Thomas  promises  very  greal  success  in  the 
treatment  of  extra-uterine  pregnancy  in  the  early  stages.  It  has  the  advan- 
tage of  less  risk  to  the  peritoneum,  less  danger  from  hemorrhage,  it  insures 
drainage  of  the  sac,  more  thorough  disinfection,  ami  therefore  less  danger 
from  septicaemia. 

More  recently  he  advises  leaving  the  placenta  in  situ  and  Idling  tin  sac 
with  antiseptic  cotton,  which  should  be  removed  once  in  thirty-six  hours. 

If  no  obstacle  can  be  opposed  to  the  constant  development  of  the  foetus, 
every  operation  must  be  proscribed  at  this  period  for  extracting  the  foetus 
from  its  mother's   body,  because   an  operation  would  be  as  dangerous  as  the 

anticipated  accident.     Even  when  the  spontaneous  rupture  of  the   cyst, 


(i02  PATHOLOGY    OF     PKEGNANCY. 

during  tlic  early  stages,  occasions  a  just  fear  of  mortal  hemorrhage,  we 
can  only  employ  those  general  means  which  arc  the  best  calculated  to 
prevent  profuse  discharges,  such  as  rest,  refrigerants,  etc.  Again,  suppos- 
ing thai  a  well-marked  case  of  extra-uterine  pregnancy  lias  advanced 
almost  to  term,  or  that  the  labor  lias  actually  commenced,  we  may  still 
justly  dread  the  laceration  of  the  cyst  as  a  consequence  of  the  expulsive 
efforts;  and  the  question  then  arises  whether  gastrotomy,  which  has  been 
successfully  practised  in  similar  cases,  ought  to  he  resorted  to.  If  the 
child's  safety  he  alone  considered,  this  question  is  easily  resolved.  But 
is  not  the  life  of  the  mother  almost  necessarily  compromised  by  such  an 
operation  ? 

How  shall  we  persuade  the  patient,  when  the  proper  period  for  operating 
has  arrived,  if  she  herself  does  not  suspect  the  danger  she  encounters  by 
refusing  ?  Or  how,  indeed,  can  we  ourselves  decide,  when  the  possible  con- 
sequences are  foreseen,  the  whole  difficulties  of  a  delivery  appreciated,  and 
the  necessity  staring  us  in  the  face  of  leaving  open  in  the  abdomen  a  vast 
cyst,  the  inflammation  and  suppuration  of  which  are  so  difficult  to  dry  up, 
and  are  of  themselves  sufficient  to  endanger  the  sufferer's  life? 

In  such  cases,  who  can  doubt,  says  M.  Dezeimeris,  that  if  there  was  any 
measure  at  all  that  could  suspend  the  commencing  labor,  the  ties  of  human- 
ity alone  would  render  its  employment  a  duty  ?  And  I  fully  embrace  the 
same  opinion. 

Now  among  the  means  calculated  to  restrain  the  ordinary  uterine  con- 
tractions, I  know  of  nothing  more  serviceable  than  opium,  when  exhibited 
in  large  doses  per  anum,  and  I  certainly  should  not  hesitate  to  employ  it 
under  these  circumstances ;  but  if  the  labor  continues,  notwithstanding  its 
use,  gastrotomy  may  then  be  authorized. 

The  cyst  is  generally  opened  through  the  abdominal  parietes,  the  place 
of  selection  being  the  same  as  in  the  common  Cesarean  operation,  though, 
in  case  the  head  be  felt  through  the  vagina  during  the  expulsive  efforts, 
less  danger  would  certainly  accompany  an  incision  through  the  walls  of  the 
latter.  The  child  may  be  extracted  by  turning,  or  by  the  forceps,  if  neces- 
sary. Parry  collected  15  cases  in  which  vaginotomy  was  performed.  In 
these,  nine  of  the  mothers  died  and  six  lived — a  mortality  of  (in  per  cent. 
In  primary  gastrotomy  the  mortality  is  70  per  cent.  The  death  rate  of  extra- 
uterine pregnancy,  not  actively  interfered  with,  is  shown  to  be  52.65  per  cent. 
If  a  prolonged  labor  has  produced  a  rupture  of  the  cyst,  it  is  very 
doubtful  whether  gastrotomy  could  he  successful.  The  first  efforts  should 
he  directed  towards  moderating  the  hemorrhage,  and  opposing  consecutive 
inflammation  should  he  energetically  employed. 

But  the  primitive  phenomena  once  calmed,  whether  there  be  a  rupture  or 
not,  our  art  may  evidently  interpose  to  prevent  the  consecutive  accidents 
(hat  have  been  enumerated,  and  which  compromise  to  so  great  an  extent 
the  health  and  even  the  life  of  the  patient.  When  the  inflammatory  symp- 
toms have  ceased,  it  is  proper  to  wait ;  and  especially  after  the  cyst  is 
ruptured,  hasty  action  becomes  unnecessary. 

In  fact,  a  considerable  period  is  requisite  in  such  cases  for  the  develop- 
ment of  a  new  cyst  around  the  displaced  parts,  and  a  certain  length  of  time 


Or    EXTRA-UTERINE    PREGNANCY.  603 

is  necessary  for  the  adhesions  to  form  between  them  and  the  adjacent  parts, 
and  it  would  be  exceedingly  rash  to  interfere  with  this  salutary  action  by 
any  inopportune  operation  on  our  part.  In  old  abnormal  pregnancies,  the 
resources  of  art  vary  with  the  particular  case.  Sometimes,  indeed,  an  elimi- 
natory  effort  has  already  commenced  by  an  inflammation  of  the  integumenns 
placed  just  in  front  of  the  tumor,  whereby  an  abscess  is  formed;  and  the 
only  question  then  is,  whether  to  open  it,  or  by  suitable  incisions  to  enlarge 
the  spontaneous  solutions  of  continuity  ;  in  either  case  we  encounter  a  vast 
abscess,  which  must  be  emptied  and  cleansed  by  the  usual  methods. 

When  some  portions  of  the  foetus  get  into  the  bladder,  and  we  are  assured 
of  that  fact  by  the  use  of  the  catheter,  the  operation  for  stone  may  be  prac- 
tised either  through  the  vagina  or  by  the  hypogastrium.     Again,  a  woman 
may  present  herself  with  an  extra-uterine  fetus  of  one  or  several  years' 
standing.     Can  the  resources  of  art  afford  her  any  relief?     We  reply,  that 
if  the  gestation  is  a  source  of  severe  suffering,  and  it  renders  her  incapable 
of  discharging  her  duties ;  and  if,  besides,  the  tumor  may  be  reached  through 
the  vagina  without  difficulty,  the  vaginal  incision  should  doubtless  be  per- 
formed.    But  if  she  is  otherwise  in  good  health,  would  it  be  prudent  to 
interfere  for  the  mere  purpose  of  anticipating  the  accidents  to  which  she 
will  probably  be  afterwards  exposed?     Or  is  there  any  ground  for  hoping 
to  extract  the  foetus  en  masse,  by  a  prudent  and  methodical  operation? 
This  last  question  is  far  more  difficult  to  solve.     In  a  case  of  this  kind, 
where  the  head  of  the  foetus,  from  being  wedged  at  the  superior  strait,  could 
readily  be  felt  through  the  posterior  superior  part  of  the  vaginal  parietes, 
I  knew  Professor  P.  Dubois  (notwithstanding  sharp  opposition  from  several 
of  his  brethren  in  consultation)  to  resolve  upon  incising  freely  the  vaginal 
wall,  as  well  as  the  cystic  envelopes,  intending  to  apply  the  forceps  on  the 
head,  and   thus  extract  the  foetus  bodily ;  but  the  walls  of  the  cyst  and 
vagina  having  been    cut  through,  an  intimate   adhesion  was  discovered 
l/etween  the  former  and  the  foetal  head,  which  caused  the  operation  to  be 
abandoned.     It  was  not  without  benefit,  however,  for  in  the  course  of  a  few 
days  it  was  followed  by  the  discharge  of  a  putrid  mass,  comprising  all  the 
soft  parts  of  the  foetus ;  the  detached  bones  of  the  skeleton  were  gradually 
extracted  by  the  aid  of  long  pincers,  and  frequently  repeated  injections ;  the 
cystic  walls  contracted  slowly;  and  when,  at  length,  nothing  remained,  and 
the  parietes  were  cleansed,  the  opening  gradually  closed  up,  and  by  the  end 
of  two  months  the  patient  was  completely  cured.     At  the  time  of  operating 
she  had  been  pregnant  twenty-two  months.     This  plan  oughl  to  be  followed 
up  in  similar  cases,  especially  if  the  female's  health  is  visibly  affected.     In- 
cision by  the  rectum  lias  hen  practised  in  some  few  instances  where  the 
vulva  was  obliterated.    Finally,  gastrotomy  alone  would  be  practicable  when 
the  foetus,  from  its  high  situation  in  the  abdomen,  is  inaccessible  by  the  vagina 
or  rectum.     This  operation  must  be  regarded  as  the  lasl   resource  when  the 
patient's  life  is  seriously  endangered. 

In  L875,  Prof.  T.  G.  Thomas  reported  a  case  successfully  operated  upon 
through  the  vagina  by  means  of  the  platinum  knife  of  the  galvano-caustic 
battery.     In  all  operations,  antiseptic  precautions  Bhould  be  \\>rd. 


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WQIOO 
C386t2 
1886 
v.  1 

Cazeaux,  Pierre. 

Theory  and  practice  of 


WQ100 

C386t2 
1886 
)a.zeauy. ,  Pierre.         v.  1 
Theory  and  practice  of  obstetrics 


MEDICAL  SCIENCES  LIBRARY 

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